18: Esophageal and Gastric

Question 1

What are the two main type of Esophageal Cancers and where are they commonly located?

Answer 1

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

Question 2

What are symptoms and what does that typically mean for diagnosis for esophageal cancer?

Answer 2

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

Question 3

What is a common surgery intervention for esophageal cancer? What’s a particular feeding concern if surgery is planned?

Answer 3

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

Question 4

What is a palliative treatment for dysphagia? What are the diet recommendations for this?

Answer 4

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

Question 5

What are some risk factors for EC?

Answer 5

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

Question 6

What is the rate of malnutrition in EC?

Answer 6

75% — early intervention is key

Question 7

What is the most common symptom of EC?

Answer 7

Dysphagia – usually what prompts the doctor visit for diagnosis

Question 8

What are common post-op nutrition complications in EC?

Answer 8

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

Question 9

What is the prognosis/survival rates of gastric cancer?

Answer 9

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

Question 10

What are the types of gastric cancer?

Answer 10

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

Question 11

What are risk factors for gastric cancer?

Answer 11

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

Question 12

What are symptoms of gastric cancer?

Answer 12

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

Question 13

What are the surgery options for gastric cancer? What stage cancers are possibly eligible?

Answer 13

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)

Question 14

Postop gastrectomy complications and symptoms/treatment:
Small Gastric remnant or early satiety

Answer 14

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

Question 15

Postop gastrectomy complications and symptoms/treatment:
Gastric Statis or Roux Statis Syndrome

Answer 15

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

Question 16

Postop gastrectomy complications and symptoms/treatment:
Dumping Syndrome

Answer 16

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

Question 17

Postop gastrectomy complications and symptoms/treatment:
Postvagotomy diarrhea

Answer 17

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

Question 18

Postop gastrectomy complications and symptoms/treatment:
Bile reflux gastritis

Answer 18

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

Question 19

Postop gastrectomy complications and mechanism/recommendation:
Vitamin B12 Deficiency

Answer 19

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

Question 20

Postop gastrectomy complications and mechanism/recommendation:
Folate Deficiency

Answer 20

Mech: secondary to malabsorption

Recommendation: use red blood cell folate to measure serum levels, 5 mg of folate daily if deficient

Question 21

Postop gastrectomy complications and mechanism/recommendation:
Iron Deficiency

Answer 21

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)

Question 22

Postop gastrectomy complications and mechanism/recommendation:
Bone Disease

Answer 22

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

Question 23

Postop gastrectomy complications and mechanism/recommendation:
Fat Malabsorption

Answer 23

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)