Part 13


Oesophageal cancer

Risk factors for what cancer? 

Life style factors responsible for 9/10 cases 




Reflux causes metaplasia, dysplasia -> adenocarcinoma (Barret's, 1-5%) 

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Most common type of cancer in the oesophagus (Barrets) 

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Oesophageal cancer


Persistent indigestion / heartburn 

Weight loss 

Pain in throat or behind sternum 

Peristent cough 

Regurgitation of food 

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Oesophageal cancer

T1 = mucosa / submucosa 

T2 = muscle involvement 

T3 = serosa involvement 

T4 = grown onto another body structure 

4a = pleura / pericardium / diaphragm 

4b =  trachea, vertebrae, aorta 

N1 = 1-2 nearby nodes 

N2 = 2-6 nearby nodes 

N3 = 7 or more 

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Stages 2 and 3

You give neoadjuvant chemotherapy before surgery in what stages of oesophageal cancer 

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Adenocarcinoma of the oesophagus

Treatment for? 

Epirubicin, cisplatin, caecitabine (ECX) 

Epirubicin, oxaliplatin, caecitaibne (EOX)

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Ivor-Lewis oesophago-gastrectomy

Surgical treatment for cancer in the middle and lower third of the oesophagus? 

Laparotomy / laparoscopy to mobilise stomach, right thoracotomy to resect oesophagus (minimally invasive) 

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Symptoms of stomach cancer


Weight Loss 

Persistent indigestion (dyspepsia)

Feeling full despite eating a small quantity 

Sickness / vomitting 

Meleana / haematemesis 

Tiredness / breathlessness (Fe deficient anaemia) 

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Types of gastrectomy

Roux-en-Y gastro jejunal anastomosis 

Billroth II gastrectomy: Gastro-jejunal anastomosis 

Oesophago-gastric anastomosis 

Total gastrectomy: oesophago-jejunal anastomosis 

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Type 4

What type of hypersensitivity is T1DM 

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What HLA genes are involved in T1DM 

Found on chromosome 6 

Important in MHC molecules (which present antigens to our T cells) 

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Kussmaul respiration (deep / laboured breathing) 

Hyperkalaemia (In the blood) 

But low K+ stores in the cells 

High anion gap 

Symptoms= nausea, vomitting, mental status changes and severe -> cerebral oedema 

More common in T1DM 

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Treatment for ?

Fluids - dehydration 

Insulin - to Lower blood glucose 

Electrolytes (K+) - 0.9% KCl


^ all to help reverse the acidosis 

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More common in T2DM 

Due to increased glucose in the blood, more water leaves the cells leading to increased urination and therefore total body dehydration 

Increased plasma osmolarity 

Symptoms = mental state changes (due to dehydration)

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Diabetic retinopathy

Complication of diabetes 

Fundscopy shows:

Cotton wool spots 

Flare haemorrhages 

Can result in blindness 

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Anion gap metabolic acidosis 


Acetone breathe 

Hyperkalaemia intially with hypokalaemia 

Ketones present in urine and ABG therefore pH <7.3 

Glucose >250mg/dL 

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Gram +ve = purple, Gram -ve = red

Gram stain reaction colours for: 

Gram +ve

Gram -ve 

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Gram +ve

Teichoic acid - structure

 Lipoteichioc acid - picked up by innate immune response 

Thick layer of peptidoglycan 

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Gram +ve

Survive well on drying 

Some produce spores 

Produce exotoxins 

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Gram -ve

Do not survive well on drying 

No spores 

Produce endotoxins in their cell wall 

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Ziehl-Neelsen stain

Stain used to see 

Mycobacterium (gram +ve in structure but thick waxy layer of mycolic acids)

Alcohol and acid fast bacilli 

Uses heat to drive stain into cells, cannot rid of stain. Appear bright pink with a counter stain 

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Gram -ve cocci

Neisseria meningitis - meningococcus 

Neisseria gonorrhoeae - Gonococcus 

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Gram +ve cocci in clusters

Staphlococcus aureus 

Skin, soft tissue, wound 

Blood infection -> endocarditis 

Infection bone -> osteomyelitis and joints (septic arthritis) 


Toxic shock syndrome 

+ve coagulase reaction, can convert fibrin to fibrinogen 

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Gram +ve cocci in pairs


Normal flora in oral cavity, gut, genital tract 

Group A = Streptococcus pyogens

Sore throat, impetigo, cellulitis 

Group B = streptococcus agalactiae

Neonatal sepsis 

Also a Group C and D 

Streptococcus pneumoniae (alpha haemolytic on blood agar) 

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Gram +ve rods

Anaerobic spore forming = high mortality :

Clostridium specia - C. tetani, C botulinum, C. difficile

Aerobic spore formers 

Bacillus species - B. anthracis, B cereus (important cause of food poisoning) 

Non-spore forming 

Corynebacterium diptheria, listeria sp (blood stream, meningitis, neonatal sepsis) 

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Neisseria meningitides meningitis

1 y/o child 

Flu like illness for 24hr 

Now droswy with rash 

MB report = turbid CSF, WCC = 450 (90% neutrophils, 10% monocytes), <5RBCs 

Gram stain shows multiple -ve diplococci 

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Gram -ve rods

Enterobacteriaceae - Facultative anaerobes:

Infections in UT and blood stream, bacterial food poisoning, intraabdominal infections such as appendicitis 

E-coli, klebsiella, proteus, salmonella 

Pseudomona aeruginosa - aerobe 

Blood stream and UTI; important cause of HCAI in I.c. patients 


Environmental organism causing pneumonia 

Haemophillus influenza

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Systemic inflammatory response syndrome

A clinical response arising from a non-specific insult 

Including >2 of the following 

Temp >38 or < 36 

HR > 90bpm 

RR > 20 

WBC >12,000 or < 4000 

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SIRS with a presumed or confirmed infectious cause 

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Severe sepsis

Sepsis with > 1 sign of organ failure 

Cardiovascular (refractory hypotension) -> shock 






Unexplained metabolic acidosis 

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Can bring together T cells without needing an antigen presenting cell 

Therefore a much higher inflammation resposne 

Response to inflammation much higher and therefore can cause sepsis quicker 

Found in:

Group A strep 

Staph aureus TSTT-1

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Group B strep, listeria, E-coli

Causes of neonatal sepsis 

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Management of? :

Fluids, DA, transfusion 

Resolution of precipitating problem 


Blood gases, Renal function 



Myocardial function

Give antimicrobials 

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Origin unknown or gut, renal, bilary

Co-amoxiclav (augmentin) and gentamicin 

Can add vancomycin 

Alternatives = 

Cefuroxime + metronidazole + gentamicin 

Ciprofloxacin + metronidazole + gentamicin 

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Skin or soft tissue

Glucloxacillin + penicillin (amoxicillin) 

+/- gentamicin 

(consider adding clindamycine if group A strep or staph aureus TSS) 

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Co-amoxiclav + doxycycline 


Cerfuroxime + erthyromycin 

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Meningococcal disease




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Hospital acquired infection shock

Gentamicin + piperacillin + tazobactam (tazocin) 

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