CARCINOMA OF THE STOMACH OR GASTRIC CANCER

CARCINOMA OF THE STOMACH OR GASTRIC CANCER

Introduction

most of gastric cancer detected in the UK  are advanced adenocarcinoma with an appalling overall 5- year survival rate 5-10%. in comparison , in japan , where the disease is commonest over 30%of all gastric cancers are detected early and overall 5- year survival rates exceed 50%. 

demography : the incidence of gastric cancer has fallen dramatically in the western world over the past 30 years gastric cancer is twice as common in males peaks incidence between 55 and 65 years is associated with blood group A and Helicobacter pylori and occurs more frequently amongst the lower social classes . there is a genetic link as stomach cancer run in families but environmental factors such as diet and methods of food preservation are also important

Types of gastric cancer

It can be divided into intestinal and diffuse type these are recent classification . the intestinal type matches geographical area of increased incidence and is usually accompanied by an area of chronic gastritis . the diffuse type bears no such relationship

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THYROGLOSSAL TRACT ANOMALIES

THYROGLOSSAL TRACT ANOMALIES

In order to understanding these anomalies it should be first known the development of thyroid gland

Development of thyroid gland

the thyroid gland develops from the thyroglossal duct (median bud of the pharynx) during the fourth embryonic week and passes ventrally from the foramen caecum at the back of the tongue to the pharynx just below the position of the developing hyoid cartilage . this line of descend is called the thyroglossal duct thus formed usually degenerates but it is incomplete regression results in the following 

Congenital abnormalities

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Benign prostatic hyperplasia

Benign prostatic hyperplasia

Benign prostatic hyperplasia BPH

IS INCREASINGLY COMMON WITH AGE AND IS PRESENT IN AN ESTIMATED 50%OF MEN OVER THE AGE OF 60 YERAS AND IN NEARLY 88% BY THE AGE OF 88 YEARS

THIS IS A HISTOLOGICAL DIAGNOSIS AND IS DUE TO THE HYPERPLASIA OF THE PERIURETHRAL GLAND IN THE TRANSITIONAL ZONE OF THE PROSTATE . THIS ENLARGEMENT CAUSES VARYIBG DEGREE OF OBSTRUCTION TO THE FLOW OF URINE AND LEADS TO

 A GROUP OF SYMPTOMS CATEGORIZED

AS LOWER URINARY TRACT SYMPTOMS (LUTS) . THE EXTEND OF THE PROSTATIC ENLARGEMENT MAY NOT BE DIRECTLY PROPORTIONAL TO THE DEGREE OF BLADDER OUTFLOW NOR TO THE AMOUNT OF SYMPTOMS

 THE CLINICAL DEFINITION OF BPH IS THEREFOR A COMBINATION OF LUTS , PALPABLE BENIGN  PROSTATIC ENLARGEMENT AND URODYNAMIC EVIDENCE OF BLADDER OUTFLOW OBSTRUCTION

PRESENTATION

 Patients may have no symptoms and are found to have a palpable bladder due to chronic retention of urine and occasionally in post renal obstructive renal failure LUTS can be divided into two groups

Obstructive symptoms

Associated with voiding which are hesitancy poor stream , straining , prolonged micturition postmicturition dribbling and a feeling of incomplete emptying and

Irritative symptoms

associated with filling which are frequency nocturia and urgency . patients may also present with acute retention haematuria and urinary tract infection

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DYSPHAGIA

DYSPHAGIA

Dysphagia means difficulty in swallowing

What are the causes of dysphagia ?it can be divided into

Oral causes like
 
painful conditions as stomatitis , glossitis , ulcers  mechanical factors as ankloglossia , cancer tongue cleft palate fracture or dislocation of the mandible

 Pharyngeal causes as

painful conditions like pharngitis , tonsillitis , paratonsillar abscess  mechanical factors as foreign body , retropharyngeal abscess , diverticulm , tumours , pharyngeal pouch ,

plummer vinson syndrome

hysterical causes

oesophageal causes

 as 1- in the lumen like foreign body 2- in the wall as stricture tumours , oesophagitis , scleroderma , achalasia 3- compression from outside as cancer thyroid or goitre and mediastinal syndrome 

 Cardio-oesophageal causes

as 1- achalsia 2- hiatus hernia 3- cancer cardia or lower thrid of the oesohpagus 4- reflux oesophagitis and peptic ulcer of the lower end of the oesophagus


 Discussion of commonest causes of dysphagia

Achalasia of the oeosphagus
 
 Which affect female more than male and most patient are in the third and fourth decades the onset is insidious with intermittent dysphagia often more marked with fluid than solids . regurgitation of food more several hours after meals and is often mistaken by the patient for vomiting , there may be retrosternal discomfort rarely amounting to pain . in advanced cases the nutrition suffers and loss of weight occurs

 Plummer -Venson syndrome 

Occurs in women around 40 years of age . there is long standing dysphagia due to achalasia of the circopharyngeus muscle and chronic inflammation of the mucous

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TREATMENT OF BREAST CANCER

TREATMENT OF BREAST CANCER

Treatment of breast cancer include the following methods

 Control of local disease by
   
Surgery
  
In patients without systemic disease local surgery may be curative but most patients have occult micrometastases . a mobile tumour with or without axillary lymph nodes is generally operable . prospective trials indicate no difference in 5-10 year survival rate of patients undergoing mastectomy or breast conservation (lumpectomy , wide local excision , quadrantectomy) and radiotherapy , but the local recurrence rate in the latter group is slightly higher

. Mastectomy with axillary clearance results in 5 year recurrence rate of 4%and 8% in node- negative and node - positive patients respectively

It is not yet clear if there are difference in long term survival (10-25)years between radical surgery and conservation

Subcutaneous mastectomy is indicated for prophylactic mastectomy in women at high risk of breast cancer

palliative mastectomy with or without local adjuvant treatment may be necessary to control advanced local disease anxiety and depression accompany ,mastectomy in many women but breast conservation does not protect against this many women fearing the possibility of residual or recurrent disease

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BREAST CANCER

BREAST CANCER

Breast cancer this is the commonest amongest women affecting 1 in 13 and resulting in 25000 new cases and 15000 deaths per year in the  UK . the incidence rises rapidly to 200|100000 women per year by age 45 and continues to rise into old age . one per cent of breast cancers occur in men . the severity of the problem in the UK  has led to a government directive that all women suspected of having breast cancer must offered an outpatient appointment within 2 weeks of referral nulliparous women in developed countries are increased risk of breast cancer whereas women who have their first child young and breast feed are protected . modern low dose oral contraception does not seem to increase the incidence of breast cancer . predisposing factors include oestrogen exposure unopposed by progesterone , hyperoestrogenism family history of premenopausal breast cancer , saturated dietary fats and previous benign a typical hyperplasia two important breast genes (BRCA1-  chromosome11 and BRCA2-  chromosome17)are associated with inherited breast cancer which accounts for about 5% of cases but environmental factors seem more important

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Pheochromocytoma

Pheochromocytoma

Definition

Pheochromocytoma are tumours arising from neuroectodermal cells of the adrenal medulla or extra adrenal sites they are found increased frequency in patients with hypertension MEN2a and MEN2b syndrome and von recklimghausen,s nerurofibromatosis

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TREATMENT OF CROHN,S DISEASE

 TREATMENT OF CROHN,S DISEASE

Medical treatment or Surgical treatment

Medical treatment

 as 1- 5- aminosalicylic acid - containing preparations may be of benefit , colitis responds better than small bowel disease however there are no proven benefits in reducing recurrence following resection 2- antibiotics particularly metronidazole and ciprofloxacin are effective though three months may need to be given 3- steroids are used in acute episodes though there is little to suggest that maintenance

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CROHN,S DISEASE

  

CROHN,S DISEASE

Definition

This is a chronic granulomatous inflammatory condition that

can involve any part of the gastrointestinal tract . it may occur at any age and the sex distribution is equal the most common site affected is the terminal ileum . this is involved in 70% of patients , giving rise to the soubriquet of (terminal ileitis) or (regional ileitis) the colon may also be involved and crohn,s colitis is the only manifestation of the disease in 20%of cases . multiple sites are common . crohn,s disease occurs in a discontinuous pattern within the bowel such that affected areas may be separated by quite normal bowel . these affected areas are termed skip-lesions 
Pathology

,Macroscopically the bowel wall becomes grossly thickened and enveloped in mesenteric fat (fat wrapping). the histological hallmark is non - caseating granuloma . this may not be found in up to 40%of specimens however . there is transmural chronic inflammation of the affected bowel with local lymphadenopathy . various aetiological theories exist , including genetic autoimmune viral and mycobacterial infections though a complex polygenic aetiology is the most likely . there appears to be strong relationship with smoking

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MANAGEMENT OF ACUTE PANCREATITIS

MANAGEMENT  OF ACUTE PANCREATITIS

non- operative management

repeated and careful clinical assessment of all patients during the first 25 hours is essential as the course of the disease is unpredictable during this time . a chest radiography is mandatory as is estimation of arterial blood gases daily for the first 48 hours and oxygen should be administered by mask if there is hypoxaemia . plain abdominal radiographs may show a sentinel loop, pancreatic calcification or calcified gall stones . vital signs and urine output should be monitored hourly . the severely affected patient should be managed on the intensive care unit . oral intake is withheld so adequate fluid replacement , especially of colloid is necessary . energetic fluid replacement is the single most important therapeutic measure since a large volume of protein rich fluid is sequestered in the

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