19: Liver, Bile Duct, Gallbladder, SB, Colon/Rectum/Anus

Question 1

What types of cancers are considers gastrointestinal cancers?

Answer 1

Hepatocellular carcinoma (HCC)
cholangiocarcinoma (CCA)
gallbladder carcinoma (GBC)
neuroendocrine tumor of small bowel (GI NET)
colorectal cancer (CRC)
anal carcinoma (AC)

Question 2

What are some risk factors for: HCC

Answer 2

males more than females
obesity
smoking, particularly with drinking or hepatitis
alcohol —- more than 45 g/day
chronic conditions impacting the liver—hepatitis, cirrhosis, DM

Question 3

What are some risk factors for: GBC

Answer 3

female more than males
obesity
mexicans and native americans at higher risk
salmonella or H pylori infection
sweetened beverages

Question 4

What are some risk factors for: CCA

Answer 4

syndromes like Lynch or Metabolic
Hepatitis
cholestatis of bilary tract/bile duct cysts
parasitic infection from liver flukes in undercooked fish

Question 5

What are some risk factors for: CRC

Answer 5

smoking and drinking
black males
multifactorial ethnic disparities due to access of care
lynch syndrome
GI conditions likes chronic and UC
family hx —1st degree relatives doubles risk
high intake of red and processed meats

Question 6

What are some risk factors for: AC

Answer 6

HPV
HIV and immune suppression
organ transplant
STDs

Question 7

name the common issues seen in GI cancers

Answer 7

SBS/diarrhea from resection
Enterocutaneous fistulas
changes in bowel movements
Bit B12 deficiency

Question 8

what type of cancer is the 2nd leading cause of cancer related deaths worldwide?

Answer 8

HCC — 83% occur in developing countries. Lower in US but opioid. epidemic has resulted in doubled incidence in 20-39 year olds

Question 9

what is a unique, possible treatment option for HCC?

Answer 9

liver transplant — has to be resectable in the first place and patient has to be a transplant candidate.

Question 10

What is the sole curative treatment option for CCA?

Answer 10

surgery — however many are deemed unresectable via ex lap

if able to have it, it is often a whipple surgery

Question 11

What are some basic nutrition recommendations for HCC pts?

Answer 11

kcal: 25-40 kcal/kg based on dry wt
Pro: 1.0-1.5 g/kg unless acute encephalopathy-then 1 g/kg
if cirrhosis, 1-2 mg/d of thiamin
note low selenium is linked to increased risk so check lab
may need Vit D3 and Ca

Question 12

What can be an issue with GI NET? What is a unique testing option?

Answer 12

initial symptoms are very vague - leading delayed diagnosis, can be more than 4 years

Hormone levels like 5-HIAA can be checked along with tumor marker Chromogrania A

Question 13

what are the 3 disease-specific nutrition problem/intervention for GI NET?

Answer 13

carcinoid syndrome - cutaneous flushing, abd cramps, diarrhea and right-sided valvular heart disease. To reduce this, need to avoid/limit foods that h increase tyramine and dopamine production.

Secretory diarrhea—due to serotonin-secreting tumors

niacin deficiency—can happen when niacin synthesis is limited by tryptophan diversion to serotonin production. treat with supplementation

Question 14

What foods are high in tyramine?

Answer 14

aged cheeses, alcohol, smoked and salted animal proteins, yeast extracts, fava beans, soy beans and fermented foods.

moderate sources include chocolate, peanuts, coconut, brazil nuts, raspberries, avocados, bananas, and caffeine beverages

Question 15

what foods are high in dopamine?

Answer 15

diary products
unprocessed meats like beef/chicken/turkey
omega-3 containing fish like salmon, herring and mackerel
eggs
nuts like almonds and walnuts
fruits and vegetables, but particularly bananas
dark chocolate

Question 16

what is specific/special about Secretory diarrhea?

Answer 16

it can be a differentiating feature for serotonin-secreting tumors. Clues is that the diarrhea doesn’t slow down nocturnal or with fasting and has a limited response to anti-diarrheal medications.

may need to try Ondansetron as its a serotonin receptor antagonist

Question 17

what are niacin deficiency symptoms to look for with GI NET patients?

Answer 17

scaly brown patches on arms/legs - though overt pellagra was rare

can do a high protein diet of 1.5 g/kg and possibly niacin supplementation

Question 18

What is the transit time for the small bowel and for the colon?

Answer 18

SB: 1-4 hrs
Colon: up to 10x longer, diet impacts this

Question 19

What are the genetic mutations to screen for with colon cancer? How many of the CRC cases are related?

Answer 19

APC, TP53, PI3K, KRAS, and BRAF – these are gatekeepers or growth regulatory genes and when mutated can cause cancer
80%

Question 20

What bacteria can trigger genetic mutations and can cancer development for CRC?

Answer 20

C diff
pathogenic strains of E coli and B fragilis

Question 21

What are the different surgery types you might see for CRC?

Answer 21

Colectomies — Left, Right, Sigmoid
Resections —- low anterior, abd perineal (results in a stoma), segmental

Can also sometimes see surgery use for mets — when CRC reoccurs, its often within 3 years and in the liver or lung. If isolated, resection could still be curative

Question 22

What is CRS and HIPEC? What about side effects?

Answer 22

CRS - cytoreductive surgery
HIPEC - hypothermic intraperitoneal chemotherapy

used with metastatic CRC with peritoneal carcinomatosis. Because 90% of the chemo stays in the abd, acting locally, this may potentially minimize systemic side effects. Nutrition would be impacted based on the surgery component

Question 23

What is the optimal goal for bowel movements after CRC surgery?

Answer 23

fewer than 4 movements/day - somewhat more formed to avoid leaking, decreasing urgency and allows for more complete elimination

Question 24

What would be the nutritional intervention for bowel management after CRC surgery?

Answer 24

1 tsp psyllium with little to no added water, BID with morning/evening meals. Best mixed with oatmeal, pudding, yogurt, mashed potatoes, applesauce, or peanut butter with no additional fluid for 1 hour before/after meals. This will assist in absorbing excess fluid and slowing transit. Increase by 1 tsp every 3-5 days to a max of 1 Tbsp BID

advise to avoid hot beverages
recommend foods that thicken stools
adjust other medications

Question 25

What is normal ileostomy output after adaptation period? Or a colostomy?

Answer 25

500-100 ml/d for ileo
200-500 ml/d for colo

Question 26

What is the hydration recommendation for ileostomy?

Answer 26

1 L more than the output
use oral rehydration solutions, sports drinks, broth and vegetable juices to address loss of fluid, sodium and potassium

Question 27

Describe low anterior resection syndrome. What can make it worse and when is it considered permanent?

Answer 27

80% of patients who undergo a resection have symptoms due to changes in anal sphincter function, sensation and rectoanal inhibitory reflex.

Symptoms include increased frequency and clustering of BMs, urgency, and incontinence or constipation with feelings of incomplete emptying

Radiation therapy can make it worse. It’s considered permanent after 2 years

Question 28

What are nutritional interventions for low anterior resection syndrome?

Answer 28

soft/low-fiber diet for 2 weeks postop

larger meals early in the day

psyllium fiber to jell stools

if stool frequency slows after 6 weeks of extensive and consistent use of antidiarrheals, may need to take Imodium AD (loperamide) 30 min before meals and bedtime or consider Rx options

might need type 3 serotonin receptor antagonist or bile acid sequestrant colesevelam to reduce urgency and frequency

sacral nerve stimulation can be considered after 1 year

Question 29

What vitamin/minerals needed to watched after CRC surgeries?

Answer 29

Serum Vit D
Calcium – recommend rich diet, supplement if needed
B12
MVI might be indicated with actual or perceived diet restrictions