Cancers of the GI Tract

Question 1

76-yr-old gentleman presents to GP complains of discomfort behind his sternum every time he eats, starts seconds after swallowing. He noticed this 3 months ago and it’s getting worse.
• As a result, he has been eating less and less. His wife, who comes to the clinic with him, says he has lost a lot of weight, although he has not noticed.
• He denies any other symptoms

No shortness of breath, palpitations, vomiting, change in bowel habit or blood in stool.
• He’s an ex-smoker (20 pack-years) with a history of mild chronic obstructive pulmonary disease, hypertension (takes one tablet) and type 2 diabetes (diet-controlled).

Examination
• Slender Caucasian, sunken cheeks – weight loss.
• HR 88, regular pulse, BP 102/70
• Dry mucous membranes – dehydration
• Jugular venous pulse not visualised
• Chest – Right basal crepitations (COPD), heart sound normal
• Abdominal examination is unremarkable – no palpable masses or organomegaly.

What is the most likely diagnosis?

Answer 1

Adenocarcinoma

Question 2

What are the causes of upper dysphagia?

Answer 2

• Structural causes: Pharyngeal cancer, pharyngeal pouch

* Neurological cause: Parkinson’s, stroke, motor neuron disease

Question 3

What are the structural causes of upper dysphagia?

Answer 3

Pharyngeal cancer, pharyngeal pouch

Question 4

What are the neurological causes of upper dysphagia?

Answer 4

Parkinson’s, stroke, motor neuron disease

Question 5

What is odynophagia?

Answer 5

Food painful upon swallowing

Question 6

What are the structural causes of lower dysphagia?

Answer 6

Inside structural cause (mural or luminal)
• Oesophageal or gastric cancer- distorts oesophageal patency.
• Stricture – Query history of reflux.
• Schatzki ring – Thickening of the mucosa (circular band), narrowing the lumen of the oesophagus.

Question 7

What is Schatzki ring?

Answer 7

Thickening of the mucosa (circular band), narrowing the lumen of the oesophagus.

Question 8

What are the neurological causes lower dysphagia?

Answer 8

Achalasia, diffuse oesophageal spasm.

Question 9

What are the cardiac causes of lower dysphagia?

Answer 9

• Blood shifts to bowel for digestion, limiting blood supply through narrowed coronary arteries – hypoperfusion of cardiac muscle.
• Unusual for angina to occur exclusively after eating – explore exertional chest pain.

Question 10

What is aspiration pneumonia?

Answer 10

• Aspiration pneumonia- regurgitated of food and is aspirated through the right primary bronchus.

Question 11

What type of imaging is conducted to diagnose a patient with an adenocarcinoma?

Answer 11

PET/CT scan

The endoscopy reveals the internal lumen of the oesophagus to be constricted by an adenocarcinoma that extends outwards towards the wall.
• PET scan, sagittal view – the oesophageal lesion is bright suggesting regions of excessive metabolic activity – due to presence of cancer cells.
• Bright spot suggests lymph node involvement – therefore N1
• T3N1M0 (Extends to the adventitia, however, does not invade other tissues).

Question 12

What is a 0 performance status?

Answer 12

Asymptomatic, and fully active

Question 13

What is PS1?

Answer 13

Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature

Question 14

What PS2?

Answer 14

Ambulatory and capable of all self-care but unable to carry out any work activities, up and about more than 50% of walking hours

Question 15

What is PS3?

Answer 15

Capable of only limited self-care, confined to bed on chair more than 50% of waking hours

Question 16

What is PS4?

Answer 16

Completely disabled, cannot carry on any self-care self-care.

Question 17

What are the common causes of microcytic anaemia?

Answer 17

Iron deficiency anaemia
Anemia of chronic disease
Thalssemia
Sideroblastic anaemia

Question 18

What are the common causes of normocytic anaemia?

Answer 18

Aplastic anaemia
Bleeding
Chronic disease
Haemolysis 
Endocrine disorder- hypothyroidism, and hypoadrenalism

Question 19

What are the common causes of macrocytic anaemia?

Answer 19

Foetus (pregnancy)
Alcohol excess
Thyroid disorders
Reticulocytosis
B12/Folate deficiency
Cirrhosis. 

FAT RBC

Question 20

How is iron deficiency anaemia caused, in terms of blood loss?

Answer 20

• Increased demand (growth, pregnancy)

* Decreased absorption

Question 21

What are the GI causes of iron deficiency anaemia?

Answer 21

1. Aspirin/NSAID use
2. Colonic adenocarcinoma
3. Gastric carcinoma
4. Benign gastric ulcer
5. Angiodysplasia  Abnormal development of blood vessels within the gastrointestinal tract.
6. Coeliac disease
7. Gastrectomy (decreased absorption)
8. H. pylori

Question 22

What are the non-GI causes of iron deficiency anaemia?

Answer 22

1. Menstruation
2. Blood donation
3. Haematuria (1% of iron deficiency anaemia)
4. Epistaxis

Question 23

What are the four main symptoms with colorectal cancer?

Answer 23

• Change in bowel habit
• Blood or mucous in stool
• Faecal incontinence
• Feeling of incomplete emptying of bowels (tenesmus)

Question 24

What are the general symptoms of a malignancy?

Answer 24

Weight loss, anorexia, malaise

Question 25

What are the specific symptoms of an Upper GI cancer?

Answer 25

Dysphagia and Dyspepsia

Question 26

How is an adenocarcinoma diagnosed?

Answer 26

Colonoscopy and biopsy confirm adenocarcinoma of the descending colon – there is growth within the lumen of the bowel manifesting as blockage.

Question 27

A urine dipstick will reveal a positive result in a patient with GI cancer how?

Answer 27

Haematuria

Question 28

What autoantibody is implicated in coeliac disease?

Answer 28

Anti-TTG

Question 29

What is the main surgical intervention for a GI cancer?

Answer 29

• The proximal bowel is dilated suggesting that there is partial obstruction of the bowel by tumour, fluid accumulation.
• Resect primary colonic tumour followed by neoadjuvant chemotherapy and then liver resection.

Question 30

What is the palliative route for bowel cancer?

Answer 30

• Palliative route – stenting to open up the lumen of the bowel in order to alleviate the partial obstruction.