Cancers of the GI Tract Tutorial Flashcards
Case 1 - 76M PC to GP = discomfort behind sternum every time he eats Started 3 months ago, getting worse Wife says he has lost a lot of weight No other symptoms
PMH = ex-smoker (20 pack-years), mild COPD, hypertension, T2DM (diet-controlled)
SH = lives with wife, looks after gradnchildren2-3x a week
What examinations should be performed?
Inspection HR BP Pulses Chest sounds Abdominal examination
On examination, it is found:
Slender Caucasian male, sunken cheeks.
HR 88, Regular pulse, BP 102/70
Dry mucous membranes.
Jugular venous pulse not visualised.
Chest – Rt basal crepitations, heart sounds are normal.
Abdominal examination is unremarkable. There are no palpable masses or organomegaly
What is the differential diagnosis?
Abdominal: Causes of dysphagia
Upper dysphagia =
- Structural causes: Pharyngeal cancer, pharyngeal pouch
- Neurological causes: Parkinson’s, stroke, motor neuron disease
Lower dysphagia =
Structural causes:
- Inside (mural and luminal): oesophageal or gastric cancer, stricture, Schatzki ring
- Outside (extrinsic compression): lung cancer
- Neurological causes: Achalasia, diffuse oesophageal spasm
Cardiac: Post-prandial angina
Other: Globus sensation/anxiety
What symptoms differentiate between cardiac pain or dysphagia?
Angina can occur after meals (blood shifts to bowel for digestion, limiting blood supply through narrowed coronaries)
However, history of discomfort seconds after swallowing is inconsistent
Unusual for angina to occur only after eating: ask about exertional chest pain
What can you ask clinically to differentiate between upper and lower oesophagus origina?
Upper = Is the food painful on swallowing?
Lower = Is food easy to swallow but feels stuck seconds later?
What can you ask clinically to differentiate etween a mechanical or neurological cause?
Likely neurological = Are both solids and liquids hard to swallow?
If it is a mechanical cause of dysphagia, how can you determine whether the patient is at risk of strictures?
Ask about history of reflex
What could blood in stool suggest?
GI malignancy
Good to perform digital rectal examination
What is the differential diagnosis now? (most likely scenario)
Malignant oesophageal lesion
Or Benign oesophageal stricture
Also potentially -
peptic ulcer disease
Which of the differentials is most important to investigate / rule out?
Malignant oesophageal lesion
What investigations would you request?
Bedsides = Blood tests = Imaging = Microbiology = Special/invasive =
Bedsides = ECG (signs of cardiac issues?)
Blood tests = FBC (iron deficiency anaemia from chronic GI bleed?), urea and electrolytes (dehydration from poor oral intake?)
Imaging = CXR (basal crepitations Rt LL)
Microbiology = None required, do not suspect infectious cause
Special/invasive = Urgent upper GI endoscopy through the 2-week-wait suspected cancer pathway
Results =
Anaemic = low Hb
Alb = low
Reflects poor nutritional state of this patient
ECG shows sinus tachycardia
CXR - aspiration pneumonia (RUL) - reflects crackles from examination
What can cause aspiration pneumonia?
Food regurgitates - travels down trachea instead
Causes aspiration pneumonia
Upper GI endoscopy - OGD and biopsy confirms adenocarcinoma of the lower oesophagus
What will the upper GI MDT need to consider when deciding the treatment approach?
3 further tests:
Staging CT CAP - lumen of oesophagus squashed due to cancer mass
PET Scan - shows lymph node with metastases and primary mass in the lower oesophagus
Staging laparoscopy
How do you stage oesophageal cancer?
What is the stage of the patient’s cancer?
Tricky to stage - requires as much info as possible
T3N1M0
T3 = goes to outerlayer of oesophagus, but does not invade other structures of the mediastinum N1 = 1 lymph node involve M0 = no other metastases
What are the treatment options for T3N1M0?
Surgery = yes, surgery resection
How is it determined whether a patient is fit enough for surgery?
ECOG = grades 0-5 referring to fitness / performance status of the person
0 = fully active, able to carry on all pre-disease performance without any restriction
1 = Restricted in phyically stenuous activity but ambulatory and able to carry out work of light nature e.g. light housework, office work, etc.
2 = Ambulatory and capable of selfcare but unable to carry out any work activities (up and about over 50% of waking hours)
3 = Capable of only limited selfcare, confined to bed or chair for more than 50% of waking hours
4 = Completely disabled, cannot carry on any selfcare, totally confirned to bed or chair
5 = Dead
Is surgery suitable for the patient?
Yes - In his 70s but v. fit
Patient undergos chemoradiation, then surgery
Case 2 - 68F
PMH - hypertension (presccribed Ramipril recently = ACEi), diabetic
What is required when woman starts ramipril for hypertension?
Initial set of blood tests (control / baseline), then a repeat of the blood tests 7 days after Ramipril is started = important as ACE inhibitors may cause deterioration of renal funciton
Kidney function due to side effects of ACEi
Her results show:
Low Hb = anaemia
MCV = low = microcytic anaemia
Elevated creatinine - refers to CKD secondary to diabetes
HbA1c = higher than someone with well controlled diabetes
What are the causes of microcytic anaemia?
Anaemia + MCV <80
- Iron deficiency = most common
- Anaemia of chronic disease
- Thalassaemia
- Sideroblastic anaemia
What are the causes of normocytic anaemia?
Anaemia + MCV 80-96
Use ABCDE acronym:
Aplastic anaemia Bleeding Chronic disease Destruction (haemolysis) Endocrine disorders - Hypothyroidism - Hypoadrenalism
What are the causes of macrocytic anaemia?
Anaemia + MCV>96
Use FAT RBC acronym:
Foetus (pregnancy) Alcohol excess Thyroid disorders Reticulocytosis B12/Folate deficiency (most common) Cirrhosis
What are the causes of iron deficiency anaemia?
3 broad causes of iron deficiency anaemia:
- Blood loss
- Increased demand (e.g. growth, pregnancy)
- Decreased absorption
GI causes =
- Aspirin/NSAID use
- Colonic adenocarcinoma
- Gastric carcinoma
- Benign gastric ulcer
- Angiodysplasia
- Coeliac disease
- Gastrectomy (decreased absorption)
- H.pylori
Non-GI causes =
- Menstruation
- Blood donation
- Haematuria (1% of iron deficiency anaemias)
- Epistaxis
What do you ask the patient at the next visit to explore the microcytic anaemia further?
Further symptoms to narrow down differentials, e.g. Blood in stool? Weight loss? Anorexia? Changes in bowel habit? Dysphagia? Dyspepsia? Faecal incontinence? etc.
What questions could you ask to determine whether the patient has noticed any overt bleeding?
Blood in stool?
Blood in urine? (haematuria)
Nosebleeds? (epitaxis)
Coughing up blood? (haemoptysis)
What are some generic symptoms of malignancy?
Weight loss
Anorexia
Malaise (fever)
What are some symptoms that may suggest colorectal cancer?
Change in bowel habit
Blood or mucus in stool
Faecal incontinence
Feeling of incomplete emptying of bowels (tenesmus)
What are some symptoms that may suggest an upper GI cancer?
Dysphagia
Dyspepsia
What examinations / investigations are appropriate to check for blood in stool / urine?
Perform a digital rectal examination.
Dip the urine to check for blood.
Patient says: Looser stool - unsure of blood Weight loss over past few months Examination - digital rectal exam = blood on glove No palpable masses in the rectum
What is the differential diagnosis and what needs to be rules out?
Crohn's UC colorectal cancer - must rule this out Haemorrhoid Coeliac disease
What investigations should be requested?
Bedsides = Blood tests = Imaging = Microbiology = Special/invasive =
Bedsides = urine dipstick (haematuria)
Blood tests = Iron studies (needed to confirm iron deficiency as the cause of microcytic anaemia), anti-TTG (a screening test for coeliac disease)
Imaging = Unlikely to order any from the GP clinic
Microbiology = None required
Special/invasive = urgent colonoscopy through the 2-week-wait suspected cancer pathway. If this is negative, an upper GI endoscopy will be organised
Negative urine dipstick - not haematuria
Blood Tests reveal she does not have coeliac disease
Colonoscopy & Biopsy confirms adenocarcinoma of the descending colon
What investigations will the lower GI MDT ask for to stage the cancer?
Staging CT scan - this usually performed alone, colorectal = easy to stage
PET scan - used only if unsure about spread to lymph nodes
Staging laparoscopy - not really required
CT scan shows dilated proximal bowel and filled with fluid (slowly obstructing bowel), lesion descending colon, liver metastases (segmenta II, III and VI)
What is the stage of colorectal cancer in this patient?
T3N0M1
Bowel cancer with liver metastasis
These are the treatment options below:
Palliative chemo Palliative care Surgery Colonic stent Resect primary tumour followed by chemo followed by resection of liver
Which one is most suitable for the patient?
Preferrable choice = resect primary tumour followed by chemo followed by resection of liver - best standard of care
The rest are less suitable because:
Palliative chemo - lady has resectable cancer, palliative = not trying to cure (unless patient wants this option)
Palliative care - resectable cancer, (unless patient wants this option)
Surgery - lot of stress on body combining 2 major surgeries = not ideal, also liver metastases = shrunk by chemo = better; also smaller metastases = hidden = can be revealed after some time
Colonic stent - only sorts out obstruction, not long term problem solver
