15. GI Malignancy

Question 1

What are the two types of malignancy that can cause dysphagia? What type of epithelium does each develop from?

Answer 1

Oesophageal squamous cell carcinoma (from stratified squamous epithelium).
Oesophageal adenocarcinoma (can result from Barrett's oesophagus in lower third of oesophagus, is from columnar epithelium).

Question 2

What are the red flags of dysphagia?

Answer 2

'ALARM':
Anaemia.
Loss of weight.
Anorexia.
Recent onset of progressive symptoms.
Masses/Malaena.

Question 3

Give 2 risk factors form oesophageal carcinoma

Answer 3

Smoking.
Obesity.
Barrett’s.

Question 4

If a patient presents with epigastric pain, what are the two other red flag signs that mean you should consider a malignancy?

Answer 4

Malaena.

Haematemasis.

Question 5

Where in the stomach do gastric cancers usually occur, and what type of cancer are they usually?

Answer 5

Cardia or antrum.

Adenocarcinomas.

Question 6

How do gastric cancers usually present?

Answer 6

Similar pain to a peptic ulcer (dull, sharp or burning), and 50% of patients will have a palatable mass.

Question 7

Give 2 risk factors for gastric cancer

Answer 7

Smoking.
High salt diet.
Family history.

Question 8

Give 2 other cancers that can occur in the stomach. How do they present?

Answer 8

Gastric lymphoma - MALT tissue, most of which are associated with H pylori and present similarly to gastric carcinoma.
Gastrointestinal stromal tumours (GISTs) - sarcomas. Tend to be an incidental finding on endoscopy.

Question 9

Where is the problem in pre-hepatic, hepatic and post-hepatic jaundice?

Answer 9

Pre-hepatic - too much haem.
Hepatic - reduced liver function.
Post-hepatic - typically obstructive causes.

Question 10

What are the other red flag sings for cancer if a patient presents with jaundice?

Answer 10

Hepatomegally (irregular border).
Ascites.
Painless.
Unintentional weight loss.

Question 11

Primary malignancy of the liver is very rare (and is typically linked to an underlying disease), but what type of cancer is it?

Answer 11

Hepatocellular carcinoma.

Question 12

Why is the liver a common site for metastases?

Answer 12

Drains the entirety of the GI tract via the portal system.

Question 13

Give 3 malignancies that commonly metastasise to the liver

Answer 13

GI.
Breast.
Prostate.

Question 14

What is Courvoisier’s law?

Answer 14

If there is an enlarged palpable non tender gallbladder, the cause is not gallstones.

Question 15

How does pancreatic cancer of the head vs body/tail present?

Answer 15

Head - painless jaundice.

Body/tail - more vague eg sickness, bowel changes, fever.

Question 16

What are most types of pancreatic cancer?

Answer 16

Ductal adenocarcinomas.

Question 17

Give 2 risk factors for pancreatic cancer.

Answer 17

Family history.
Smoking.
Male.
Age.
Chronic pancreatitis.

Question 18

Give 3 symptoms of lower GI obstruction, and two accompanying reg flags that would make you concerned about cancer.

Answer 18

Abdominal distension.
Abdominal pain.
Constipation.
Nausea and vomiting.
Red flags - unexplained abdominal pain and unintentional weight loss.

Question 19

Give two benign differential diagnoses for lower GI obstruction

Answer 19

Diverticular disease.
Volvulus.
Hernia.

Question 20

Give 2 lower GI malignancies that can lead to obstruction, PR bleeding and change in bowel habit.

Answer 20

Adenocarcinoma of the large colon.

Small bowel cancer.

Question 21

What is tenesmus?

Answer 21

Feeling of incomplete emptying of the bowels.

Question 22

Give 3 red flags for malignancy if they accompany PR bleeding and/or change in bowel habit.

Answer 22

Iron deficient anaemia.
Unexplained weight loss.
Age dependant.
Change in bowel habit.

Question 23

Give 3 benign causes of PR bleeding.

Answer 23

Haemorrhoids.
Anal tissues.
Infective gastroenteritis.
Inflammatory bowel disease.
Diverticular disease.

Question 24

Give 3 benign causes of a change in bowel habit

Answer 24

Thyroid disorder (hyperthyroid = loose stools. Hypothyroid = constipation).
Inflammatory bowel disease.
Medication related (eg opiodes = constipation).
Irritable bowel.
Coeliac disease.

Question 25

What type of cancer is large bowel cancer?

Answer 25

Adenocarcinoma

Question 26

Give 3 risk factors for large bowel cancer

Answer 26

Family history.
Inflammatory bowel disease.
Polyposis syndrome eg FAP.
Diet and lifestyle.

Question 27

What is a faecal occult blood test?

Answer 27

Detects small amounts of blood in faeces which otherwise cannot be seen. Can be used to detect blood in suspected adenocarcinoma of the large bowel.

Question 28

Describe the adenoma-carcinoma sequence relating to colorectal cancer.

Answer 28

Begins as hyperproliferation of epithelial and lamina propria cells. These progress to small then large adenomatous polyps, and then severe dysplasia which is a precancerous polyp. This contains an abnormal cell growth which becomes larger, forming an adenocarcinoma and finally an invasive cancer.

Question 29

How does a left sided colon cancer present?

Answer 29

Cancer in the sigmoid and rectum.
Wight loss, abdominal pain, rectal bleeding, bowel obstruction, tenesmus, mass in left iliac fossa, early change in bowel habit, less advanced disease at presentation.

Question 30

How does a right sided colon cancer present?

Answer 30

Ascending and transverse colon.

Weight loss, anaemia, occult bleeding, mass is right iliac fossa, disease more likely to be advanced at presentation.

Question 31

Give 3 different types of small bowel cancer

Answer 31

Stromal.
Lymphoma.
Adenocarcinoma.
Sarcoma.
Carcinoid tumours.

Question 32

Give 3 risk factors for small bowel cancer

Answer 32

Irritable bowel disease.
Coeliac disease.
Polyposis syndromes eg FAP.
Diet.

Question 33

How is cancer of the GI tract managed?

Answer 33

TNM staging.
Blood test - FBC, tumour markers (CEA).
CT/MRI.
Endoscopy/colonoscopy.
Capsule endoscopy.
Treatment - chemotherapy, radiotherapy, surgical resections.