2Helicobacter infection in the stomach is associated with: Gastric carcinomaAcute gastric ulcerationChronic duodenal ulcerationIntestinal metaplasiaGastric lymphoma
3Regarding salivary gland tumours: Malignant tumours arise most commonly in the parotid glandPleomorphic adenomas have a 20% risk of malignant transformationFacial nerve impairment is an ominous signAdenoid cystic carcinoma has a good long-term prognosisEnucleation of pleomorphic adenoma is appropriate treatment
4Barrett’s oesophagus: Is a dysplastic changeConfers an increased risk of oesophageal squamous carcinomaCan contain small intestinal-type epitheliumCan be complicated by benign oesophageal strictureIncreases in frequency with increased duration of gastro-oesophageal reflux symptoms
5Oral leucoplakia can be caused by: Candida infectionSmokingEpithelial dysplasiaIll-fitting denturesInvasive carcinoma
6Concerning gastric cancer: It is commoner in Australia than in JapanDiffuse type (signet ring) adenocarcinoma is decreasing in incidenceMany cancers arise from pre-existing benign peptic ulcersOverall 5 year survival is 25%Histological type is the most important prognostic factor
7Are common in severely ill patients Are usually >25 mm in diameter Acute gastric ulcers:Are often multipleAre common in severely ill patientsAre usually >25 mm in diameterAre confined to the antrumUsually heal without scarring
8Concerning chronic gastritis: Autoantibodies to gastrin-producing cells are present in autoimmune gastritisSquamous metaplasia is often seen on biopsyChemical gastritis can be secondary to bile refluxIt confers a high risk of development of gastric cancerIt is frequently seen in patients taking long term steroids
9Concerning squamous cell carcinoma of the mouth The incidence is higher in the far east than the UKPrognosis is best for anterior tumoursThere is an association with sun exposureThe tumour rarely spreads beyond the oral cavityErythroplakia is a high-risk factor
10A 63-year-old male presents to his GP with swallowing problems A 63-year-old male presents to his GP with swallowing problems. He describes a gradually increasing difficulty with swallowing solid food, but no problems with liquids. The has recently lost 6 kg in weight and has a several-year history of “heartburn”.
11What is your differential diagnosis based on this history? Oesophageal obstruction most likely to be due to a benign inflammatory stricture or a malignancyHx of heartburn points to GORDAchalasia (much less likely)Benign strictures – physical or chemical injury (ingested caustic substances, irradiation, chemo), scleroderma
12What changes may be present within oesophageal biopsies taken at endoscopy? In benign strictures, oesophageal mucosal biopsies may show inflammatory changes with squamous epithelial hyperplasia. Ulceration may be present. The fibrosis causing a benign stricture may not be seen histologically as the scar tissue lies deeper within the wall of the oesophagus and may not be sampled in a superficial biopsy.Inflammation and squamous hyperplasia would be seen in GORD. Identification of glandular epithelium within the anatomical oesophagus would signify Barrett’s metaplasia.If malignant tumour is present, biopsy will confirm whether this is squamous cell carcinoma, adenocarcinoma, or a more unusual tumour type (such as sarcoma or melanoma).Even if no mass is seen, in the presence of Barrett’s oesophagus there is an increased risk of malignancy and of premalignant (dysplastic) changes in the glandular epithelium. For this reason, patients known to have Barrett’s change may undergo regular endoscopies, although the effectiveness of this surveillance in identifying early-stage, potentially curable, oesophageal tumours is not yet clearly established.
13A 78-year-old female is admitted to hospital as an emergency patient with abdominal pain and haematemesis. Urgent endoscopy is performed and a 15 mm ulcer is identified in the proximal duodenum as the source of the bleeding
14What specific questions would you ask the patient to help establish the cause of the ulcer? A careful drug history to exclude NSAIDs is essential. Many elderly patients suffer from osteoarthritis and buy medications over the counter. Smoking and alcoholic liver disease are associated with peptic ulceration and the relevant history of these habits should be obtained. Other relevant medical history would include chronic lung disease, chronic renal disease and hyperparathyroidism.
15Why might the endoscopist take a biopsy from the stomach (rather than the duodenal lesion)? H. pylori gastritis is frequently present in association with peptic duodenal ulceration. A rapid urease detection test for Helicobacter can be performed with the tissue sample in the endoscopy suite, of the biopsy material can be submitted for histopathological examination. Duodenal peptic ulcers do not undergo malignant transformation and can safely be assumed benign in nature without histological confirmation.