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سه‌شنبه 6 شهریور‌ماه سال 1386
ادامه گوارش + کنسرها

 

 

                  Table 37-3. Colorectal Cancer (CRC) Screening and Surveillance Recommendations

 

Indication

Recommendations

Average risk

Any one of the following beginning at age 50:

(سابقه فردی و خانوادگی برای کنسر کولون ندارند)

  Annual fecal occult blood testing (FOBT)

 

  Flexible sigmoidoscopy every 5yr

 

  Annual FOBT plus flexible sigmoidoscopy every 5yr

 

  Double-contrast barium enema every 5yr

 

  Colonoscopy every 10yr

1-2 first-degree relatives with CRC at any age or adenoma(s) at age <60

Same options for average risk beginning at age 40

Hereditary nonpolyposis colorectal cancer = سندرم لینچ در خانواده دارند

Genetic counseling/screening *اسکرین از 25 سالگی با کولونوسکوپی هر 1-2 سال تا 40 سالگی سپس سالی یکبار.

 

Colonoscopy every 1-2 years beginning at age 25 and then yearly after age 40

Familial adenomatous polyposis(FAP)/ Gardner's syndrome

 Genetic counseling/testing *شروع از بلوغ با سیگموئیدوسکوپی قابل انعطاف سالیانه+اسکرین برای ژن APC

 

Flexible sigmoidoscopy yearly beginning at puberty

Personal history of CRC (Colorectal Cancer)

Colonoscopy within 1yr of curative resection; repeat at 3yr and then every 5yr if normal

Personal history of colorectal adenoma(s)

Colonoscopy every 3-5yr after removal of all index polyps

Inflammatory bowel disease

Colonoscopy every 1-2yr beginning after 8yr of pancolitis or after 15yr if only left-sided disease

در مورد PSC+UC سالی یکبار کولونوسکوپی می کنیم

*Whenever possible, affected relatives should be tested first because of potential false-negative results.
Screening recommendation for individuals with positive or indeterminate tests as well as for those who refuse genetic testing.

 

Congenital hypertrophy of the retinal pigment epithelium is an early benign manifestation of both FAP and Gardner's syndrome.

 

 

سندرم های پارانئوپلاستیک  در آدنوکارسینومای معده:

A variety of paraneoplastic syndromes have been associated with gastric adenocarcinoma and warrant an investigation for a gastrointestinal malignancy. They include:

Trousseau's syndrome (thrombosis),

acanthosis nigricans (pigmented dermal lesions),

membranous nephropathy,

microangiopathic hemolytic anemia,

Leser-Trélat sign (seborrheic keratosis), and

dermatomyositis.

 

نئوپلاسمهای کبدی:

 

آدنوم های کبدی

Hepatic Adenomas:

found predominantly in women of childbearing age, are associated with estrogen and oral contraceptive use, and may enlarge during pregnancy. in Men use of anabolic steroids -- usually incidentally identified -- can spontaneously hemorrhage during menstruation or pregnancy or postpartum, causing shock and requiring surgical resection-- Consist of normal hepatocytes without portal tracts and Kupffer cells.

The diagnosis is suggested by the appearance of a cold spot on technetium-99m-sulfur colloid scans (resulting from absence of Kupffer cells) and of vascular lesions on angiography.

The appearance on ultrasonography, computed tomography, and magnetic resonance imaging is nonspecific, but a characteristic feature is the presence of a well-defined capsule.

 

همانژیوم های کبدی:

Hemangiomas

are the most common mesenchymal hepatic neoplasms -- prevalence in the general population of 2 to 5%-- usually discovered incidentally--most often solitary and located in the right lobe of the liver.

Right upper quadrant abdominal pain may occur in patients with large lesions (typically > 5 cm) owing to the development of intratumoral hemorrhage and thrombosis.

Diagnosisà readily made when a hyperechoic lesion on ultrasound evaluation corresponds to a peripheral enhancing lesion that eventually completely fills during dynamic computed tomography, when MRI reveals a high-intensity signal on T2-weighted images (most sensitive test), or when a technetium-99m red blood cell scan (most specific test) shows retention of the isotope in the tumor.

Treatment is usually not necessary in lesions less than 5 cm. In larger lesions, close monitoring and/or elective resection has been advocated. Symptomatic lesions may be treated with embolization, enucleation, resection, and, in extreme cases, transplantation (large unresectable lesions or multiple lesions).

 

 

Table 44-1. Hepatocellular Carcinoma

 

Incidence

From 1-7 per 100,000 to >100 per 100,000 in high-risk areas

Sex

4:1 to 8:1 male preponderance

Associations

Chronic hepatitis B infection

Chronic hepatitis C infection

Hemochromatosis (with cirrhosis)

Cirrhosis (alcoholic, cryptogenic)

Aflatoxin ingestion

Thorotrast

α1-Antitrypsin deficiency

Androgen administration

Common Clinical Presentations

Abdominal pain

Abdominal mass

Weight loss

Deterioration of liver function

Unusual Manifestations

Bloody ascites

Tumor emboli (lung)

Jaundice

Hepatic or portal vein obstruction

Metabolic effects

  Erythrocytosis

  Hypercalcemia

  Hypercholesterolemia

  Hypoglycemia

  Gynecomastia

  Feminization

  Acquired porphyria

Clinical/Laboratory Findings

Hepatic bruit or friction rub

Serum α-fetoprotein level >400 ng/mL

 

 

 

Indeed, in 10 to 20% of patients, no cause for granulomas is found despite extensive investigation. A subset of these patients have a syndrome consisting of fever, hepatomegaly, and hepatic granulomas that responds to corticosteroids, described as hepatic granulomatous disease or "granulomatous hepatitis." These patients may possibly have a variant of sarcoidosis.

 

Liver biopsy (and culture, particularly for acid-fast bacteria) is of considerable value in the diagnosis of sarcoidosis, miliary tuberculosis, and disseminated histoplasmosis, because virtually all patients with these disorders have hepatic granulomas.

Characteristic granulomas are seen in many patients with primary biliary cirrhosis, and granulomas may be the first clue to Hodgkin's disease.


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