18: Esophageal and Gastric Flashcards
What are the two main type of Esophageal Cancers and where are they commonly located?
Esophageal Squamous Cells Carcinomas (ESCCs) and Esophageal Adenocarcinomas (EACs)
ESCCs are commonly in the upper 2/3s of the esophagus, originate in the inner layers
EACs are commonly in the lower third of the esophagus, originate in the inner layers and spread outward. Adenocarcinoma of the GE Junction is treated like a esophageal cancer
What are symptoms and what does that typically mean for diagnosis for esophageal cancer?
Symptoms: Dysphagia, Odynophagia, reflux-like pain, throat or back pain and weight loss
Rarely have symptoms when disease is localized – meaning its usually advanced when found
What is a common surgery intervention for esophageal cancer? What’s a particular feeding concern if surgery is planned?
If eligible, it would be esophagectomy or esophagogastrostomy. In most cases, some of the stomach is used to create the new esophagus – sometimes colon or small intestine can be used.
If the patient is expected to need a feeding tube placed prior to surgery – either for neoadjuvant treatment, already present symptoms, or for postop healing — a J-tube will be needed. PEGs aren’t used due to that impacting the stomach, which is needed fur the surgery
What is a palliative treatment for dysphagia? What are the diet recommendations for this?
Esophageal stents – can also just be used as part of neoadjuvant treatment
They are self-expanding stents and there is concern for stent migration.
Diet:
liquids followed by moist/soft/easily chewed food within 24 hours
adequate chewing
small bites or food bolus
sitting upright during/after meals
fluids with oral intake, though most fluid volume in between meals
sips of carbonated beverages if food doesn’t pass through stent
What are some risk factors for EC?
Adenocarcinoma — obesity, GERD or Barrett’s esophagus, smoking, Gender(men)/race (white)/genetics
ESCC — smoking, alcohol, gender/race(Blacks)/genetics, processed/red meats, HPV, YERBA MATE consumption, BETEL NUT Chew
What is the rate of malnutrition in EC?
75% — early intervention is key
What is the most common symptom of EC?
Dysphagia – usually what prompts the doctor visit for diagnosis
What are common post-op nutrition complications in EC?
Anastomotic complications like leaks or strictures
removal of lower esophageal sphincter causing reflux
chylothorax***
size/shape/position of postop stomach can cause delayed emptying, reflux or dumping
pylorus dysfunction, decreased gastric capacity, devascularization and resection of the vagus nerve can result in dysmotility
SIBO, EPI or bile acid malabsorption are also possible
What is the prognosis/survival rates of gastric cancer?
If localized/early-stage — more than 50% can be cured
only 10-20% of cases in the US are early-stage, while the rest have metastatic disease
with met disease – rates range from 0-50% survival at 5 years — if resectable distal. Only 10-15% if proximal gastric
What are the types of gastric cancer?
90-95% are Adenocarcinomas (rest are lymphomas, sarcomas and carcinoid)
This is separated into intestinal and diffuse adenocarcinoma
intestinal (tubular, papillary, mucinous) are well differentiated with the cells
Diffuse is undifferentiated or poorly differentiated
What are risk factors for gastric cancer?
H Pylori infection
advanced age/male
Diet — low in fruits/vegs, high in salted/smoked/preserved foods
smoking
Epstein-Barr Virus
chronic gastritis or gastric polyps
family history
What are symptoms of gastric cancer?
indigestion
postprandial bloating
Nausea
decreased appetite
reflux
More advanced: heme-positive stools, vomiting, stomach pain, jaundice, ascites, dysphagia
Malnutrition can occur in up to 80% with advanced — 10% or more wt loss in 6 months is evident in 15% of patient
What are the surgery options for gastric cancer? What stage cancers are possibly eligible?
Stages I, II, and III could possibly have any of the following:
Distal subtotal gastrectomy (if lesion is not in the fundus or cardioesophageal junction)
Proximal subtotal gastrectomy or total gastrectomy (if lesion involves the cardia)
Total gastrectomy (if tumor is diffuse or arises in the body of the stomach and extends to within 6 cm of the cardia)
Postop gastrectomy complications and symptoms/treatment:
Small Gastric remnant or early satiety
Occurs most often when 80% or more was taken
Symptoms: early satiety, epigastric pain soon after eating, vomiting
management: small volume, frequent meals, liquids separate from meals
Postop gastrectomy complications and symptoms/treatment:
Gastric Statis or Roux Statis Syndrome
Symptoms: nausea, pain, gas/bloating, postprandial fullness, symptoms relieved by vomiting
Eval: diagnosed as either early (<90 days postop) or late —- if early, r/o SBO, if late, r/o hernia, adhesive bowel obstruction, recurrence or possible stricture. will likely need GI studies/scopes
Management: prokinetic or antiemetic meds, diet modifications like small/frequent meals, liquids rather than solid foods, liquid calories and pureed foods. Might need low-fat/low-fiber. It is possible that a J-tube might be needed to maintain nutrition
Postop gastrectomy complications and symptoms/treatment:
Dumping Syndrome
Symptoms:
Early — 10-30 minutes postprandial – epigastric fullness, N/V, abd cramps, bloating, D, lightheadedness, diaphoresis, desire to lie down, borborygmus, pallor, palpitations
Late — 1-3 hours postprandial — hunger, perspiration, tremors, difficulty concentrating
Eval: symptom eval, oral glucose tolerance test, diagnostic testes could be used if needed
Management: severe cases, could use octreotide or acarbose
diet modification: limit high sugar foods, test tolerance on lactose, avoid fried/greasy foods, but test limits on fat, eat protein rich and complex carbs, specifically soluble fiber, liquids 30 minutes before/after meals but not during, 5-6 small/frequent meals, slow eating/chewing well
Postop gastrectomy complications and symptoms/treatment:
Postvagotomy diarrhea
Symptoms: episodic, explosive diarrhea unrelated to oral intake
Eval: tricky, all possible causes need to be considered
Management: watchful waiting as symptoms may improve after several months, possible diet modifications, avoiding instigating foods, fiber supplementation may help, antidiarrheal agents if needed
Postop gastrectomy complications and symptoms/treatment:
Bile reflux gastritis
Symptoms: burning epigastric pain, N with Vomiting that doesn’t relieve pain, vomitus containing bile with food, wt loss and anemia
Eval: scopes/other testing often needed as surgical management is often needed
Management: medical treatment often not helpful, differ back to doctor
Postop gastrectomy complications and mechanism/recommendation:
Vitamin B12 Deficiency
Mech: loss of gastric acid and intrinsic factor, possibly SIBO
Common in gastrectomy patients and develops in less than 1 year
Recommendation: 1000 mcg of vit B12 intramuscularly once/month or 1000-2000 mcg/d orally
Postop gastrectomy complications and mechanism/recommendation:
Folate Deficiency
Mech: secondary to malabsorption
Recommendation: use red blood cell folate to measure serum levels, 5 mg of folate daily if deficient
Postop gastrectomy complications and mechanism/recommendation:
Iron Deficiency
Mech: bypass of duodenum and less gastric acid and intrinsic factor. Occurs in 50% of patients, higher in totals
Recommendation: 200 mg of ferrous sulfate TID (67 mg of elemental iron per 200-mg tablet)
Postop gastrectomy complications and mechanism/recommendation:
Bone Disease
Mech: decrease of Ca and Vit D — Ca from reconstruction of duodenum and rapid transit, Vit D loss results in Ca deficiency as well
Recommendation: check total Ca, ionzied Ca and parathyroid levels. Check bone mineral density, increase consumption of Ca-rich foods. Increase Ca intake (1500 mg/d) if bone disease is confirmed. Monitor serum 25-hydroxyvitamin D levels
Postop gastrectomy complications and mechanism/recommendation:
Fat Malabsorption
Mech: occurs in 10% of patients, more common when duodenum is bypassed. Screen for typical symptoms for EPI, check for SIBO
Recommendation: treat SIBO if felt likely, consider pancreatic enzymes (fecal fat test in book, but not likely to be completed)
