11. GI malignancy

Question 1

what type of cancer can occur in the GI tract

Answer 1

• mostly adenocarcinomas (as most GI tract consists of columnar epithelium)
• some squamous cell carcinomas (as stratified squamous epithelium in oesophagus and anus)

Question 2

which GI cancer is most common

Answer 2

bowel - 4th most common cancer in UK

followed by pancreas, oesophagus, stomach, liver

Question 3

what is the common presentation of oesophageal cancer

Answer 3

DYSPHAGIA

Associated red flags (ALARM):

• Anaemia
• Loss of weight
• Anorexia
• Recent onset of progressive symptoms
• Mass/Malaena

Question 4

which types of cancer can occur in oesophagus

Answer 4

• mostly squamous cell carcinoma

- can have adenocarcinomas in lower 1/3 due to Barrett’s oesophagus

Question 5

what is Barrett’s oesophagus

Answer 5

METAPLASIA of stratified squamous epithelium to gastric glandular columnar epithelium

Due to persistent acid reflux (GORD)

Increased risk of metaplasia and oesophageal adenocarcinoma

Question 6

what is the likely presentation for gastric carcinoma

Answer 6

EPIGASTRIC PAIN

Associated red flags:

• malaena
• haematemesis
• palpable mass

Question 7

name an important risk factor for gastric carcinoma

Answer 7

H. pylori infection: causes chronic inflammation (often involved in gastric lymphoma (MALT tissue))

Question 8

what is the typical presentation for liver cancer

Answer 8

JAUNDICE

Associated red flags:

• hepatomegaly (with irregular border)
• ascites
• painless (if painful, more likely inflammation/infection)

Question 9

suggest 2 reasons why liver cancer might cause ascites

Answer 9

1. pressure build-up in portal system due to tumour compression
2. reduced liver function causing low albumin

Question 10

what are the common causes of liver cancer

Answer 10

• primary malignancy is rare but hepatocellular carcinoma can be associated with HepB/C-induced inflammation
• common site for metastases that spread via blood as drains entirety of GI tract. so common site for metastases from colon and other GI, but also breast and prostate

Question 11

describe the presentation of a P with pancreatic cancer of head or body/tail

Answer 11

Head of pancreas:

• painless jaundice
• +/- enlarged palpable non-tender gallbladder

Tail/body of pancreas:
- vague symptoms, e.g. abdo pain, malabsorption, endocrine disorders

Question 12

how does small intestine adenocarcinoma present

Answer 12

1. obstruction: abdominal distension, abdominal pain, nausea and vomiting
2. rectal bleed
3. change in bowel habit (frequency/consistency/discomfort)

Question 13

how does colorectal adenocarcinoma present

Answer 13

1. obstruction: abdominal distension, abdominal pain, constipation
2. rectal bleed (rectal cancers usually ulcerating)
3. change in bowel habit (frequency/consistency/discomfort)
4. tenesmus (if rectum)

Question 14

why do right-sided colon cancers often present later than left-sided

Answer 14

Right-sided: caecum and ascending colon are more distensible

Left-sided: are usually stenosing and as content is more solid, obstructive symptoms more common

Question 15

what is the colorectal adenoma-carcinoma sequence

Answer 15

benign adenomas (polyps) are the basis for most colorectal cancers, with accumulation of mutations causing dysplasia and then malignancy

Question 16

how can most bowel carcinomas be viewed

Answer 16

via a sigmoidoscope

Question 17

name 2 inherited conditions which increases occurrence of bowel carcinomas

Answer 17

1) FAMILIAL ADENOMATOUS POLYPOSIS (FAP)
- autosomal dominant mutation in ACP gene (tumour suppressor gene)
- numerous adenomas develop at early age, mainly in colon, and subsequently become malignant, with progression to adenocarcinoma by age 35

2) HEREDITARY NON-POLYPOSIS COLORECTAL CANCER (Lynch syndrome)
- autosomal dominant mutation in DNA mis-match repair genes
- also increases risk of other cancers, esp. endometrial