Chapter 19: GI cancers Flashcards by Lisa Conticello

________ is also known as the “second brain and functions as an essential component of the immune system

Small bowel (small intestine)

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Cirrhosis of the liver is associated with hepatocellular carcinoma and is often associated with (3)

Hepatitis C
Alcohol Abuse
Nonalcoholic fatty liver

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Function of the bile duct

Carries bile from the liver and gallbladder to the small intestine

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There are similar presenting symptoms for bile duct cancer and pancreatic cancer which include

Jaundice, acholic stools, wt loss

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This is a slow growing tumor of the small bowel

neuroendocrine

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Most patients with _______ cancer experience bleeding which may be mistaken for hemorrhoids

anal

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This is the main subtype of colorectal cancer

adenocarcinoma

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This is the most common (and deadliest) GI cancer after colorectal

Hepatocellular

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These are the 4 cancer sites associated with HPV

anal
oral
cervical
esophageal

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This type of GI cancer is associated w/ capsicum + other peppers and sweetened beverages

Gallbladder

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These 4 types of GI cancer are more prevalent in women than men

Small bowel PET, gallbladder, anal, colorectal

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Of the GI cancers, this one has the strongest relation with nutrition & lifestyle factors

colorectal

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This is the greatest risk factor for anal cancer

HPV

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True/false: ERAS include carb-loading

True

ERAS is aka “fast track surgery”

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______ related to gastroparesis & ileus are common post-op issues that is a major cause for readmission post GI surgery

Dehydration

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3 tips to reduce gas pains

Walking
Chewing gum
Heating pad

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T/F: Small intestinal bacterial overgrowth may be a side effect of small bowel resection

True

*Probiotics may help to reduce the risk

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What is the length requirement to define “short bowel?”

<150 cm

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3 nutritional considerations with terminal ileum resection

Monitor and replace B12
Keep vitamin D > 30 mg/dL and supplement as needed
Anal burning may mean bile acid malabsorption - consider bile acid sequestrant

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Define enterocutaneous fistula and what is the MNT?

Abnormal connection between the intestine & skin

Promote wound healing
Replace fluids/electrolytes
EN below the fisula or PN for bowel rest to support closure

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Medical management of enterocutaneous fistula

PPI (IV form) + anti-diarrheals

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What is the Bristol scale?

A way to describe stool, 1-7

1= impacted
7= fully liquid

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Is it better to titrate or hold medications to help gain control of BMs?

Titrate. Helps to prevent overcorrection and extreme swings in BMs

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What is considered a low level of Vitamin B12 in the blood

<300 pg/mL

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_____ disease limits B12 reserves

Liver

_______ and _______ are the only curative options for heaptocelluar carcinoma, however they only improve survival rate by 50%

Surgical resection Transplant *very few are resectable either d/t location or the pt being a poor candidate

2 liver-directed therapies (not surgery are) called

Ablation & embolization Ablation - energy to destroy the tissue Emobilization - blocks or reduced blood flow

T/F: Embolization should be avoided prior to hepatic resection

True because it reduces blood flow

What is TACE

Transarterial chemoemobilization often used for treatment of liver cancer

Why is chemotherapy rarely used with liver cancer?

Poorly tolerated since the liver is what processes the drugs *targeted therapies or immunotherapies used instead

What are the 3 components of the bile duct?

1. Intrahepatic - within the liver 2. Perihilar - outside the liver 3. Distal - closest to intestine

Whipple is the sole curative intention for ______ or ______ choliangiocarcinoma

Perihilar Distal

Palliative intervention for choliangiocarcinoma (2)

1. Bile duct stenting (improves survival, plastic < metal) 2. External biliary drain placement

Bile salts recycle in the ________

illeum

If an external billary drain is used, the bile salt acid pool will be reduced. This may cause malabsorption. This can be overcome by reinfusion of biliary secretions of ________- ________ mL every ______ - _______ hours via the y-port to coincide with enteral feedings (may need semielemental)

100-200 4-6

Is glutamine supplementation recommended for acute encephalopathy?

No - glutamine turns into ammoina and will worsen it

Vitamin/mineral supplementation for cirrhosis

Thiamin, 1-2 mg/day

Hepatocellular caricnoma is linked to low levels of this micronutrient

Selenium

Sodium restriction for ascites related to liver compromise

2-3 g/day

3 strategized to maximize nutrition status with hepatic compromise

1. 6 small meals/snacks with CHO rich snack at bedtime 2. Minimize time without nutrition d/t decreased glycogen stores (may need dextrose containing IV) 3. Frequently need ONS

T/F: There is increased risk for osteoporosis with hepatic compomise

True

Calculations to adjust dry wt with ascites

Mild: 3-5 kg Moderate: 7-9 kcal Severe: 14-15 kg

How does the gallbladder help the pancreas with digestion?

Secretes alkaline bile acids which neutralize stomach acid and allow the pancreatic enzymes to work in the SI

Small intestine neuroendocrine tumors can either be functional or non-functional. Functional produce an excess of _____________ and other hormones

Serotonin

__________________ is used as a tumor marker for GI neuroendocrine tumors and is elevated in 90% of patients

Chromogranin A

_____________ receptors are found on neuroendocrine cells

Somatostatin

What is Somatostatin Analogue Therapy?

Drug that is similar to the hormone somatostatin. Somatostatin is responsible for the release of other hormones. Somatostatin analogues reduce the amount of hormones secreted from functional NET and help to stabilize tumor growth. Side effect is malabsorption d/t limiting pancreatic and gallbladder function.

In addition to somatostatin analogue therapy, peptide receptor radionuclide therapy is a ____________________ that delivers cytoxic compounds to the tumor

Radiopharmaceutical

What is carcinoid syndrome?

Flushing, abdominal cramps, diarrhea, valvular heart disease which often occurs with metastatic GI NET. It's due to serotonin secreted by the tumor.

What types of food should be limited w/ NET since they stimulate excess serotonin Y& lead to carcinoid symptoms of diarrhea & flushing?

Sources of tyramine & dopamine Tyramine: Aged cheese, alcohol, smoked/salted meats, fava beans, soybeans, fermented foods Dopamine: dairy, unprocessed meats, omega-3 rich fish, bananas, eggs, nuts

What is the maintain symptom of carcinoid syndrome? What are the 5 Es?

Dry flushing of the upper body without persperation. Eating Epinephrine Emotion Ethanol Exercise *may also need to limit spicy foods

Secretory diarrhea is a differentiating feature of ___________ tumors

serotonin-secreting

What is secretory diarrhea?

D/t serotonin secreting tumors as a result of extremely rapid GI transit time that does not slow nocturnally or with fasting and only has a limited response to anti-diarrheals Ondansetron may help since it's a serotonin receptor antagonist

Enterade may possibly be beneficial for management of ____________

Secretory diarrhea

________ deficiency can occur when synthesis is limited by tryptophan diversion to serotonin production

Niacin **recommend a high protein diet and niacinamide supplementation (20-50 mg 2x/day)

When colorectal cancer recurs, it's typically within _____ years and most often in the ______ or ______

3 liver or lung

Cytoreductive surgery and HIPEC are typically used for treatment of _______________

metastatic colorectal cancer with peritoneal carcinomatosis **often requires 2 weeks of EN or PN

What is the sigmoid colon?

The end, between the descending colon and the anus

What is the goal for number of BMs post-colorectal surgery

Firm, formed stool with fewer than 4 BMs per day

3 tips to slow transit time post colorectal surgery

1. 1 teaspoon psyllium twice daily with (morning and evening meals). Mix with oatmeal, pudding, yogurt (not water) and don't drink fluid for 1 hour before and after meals. Increase by 1 teaspoon every 3-5 days to a max of 1T twice daily 2. Avoid hot beverages 3. Use foods to thicken stools (like marshmellow)

What is the max recommendation for psyllium?

1T twice daily (6 teaspoons total)

Ostomies are more common when involving the _________

Rectum

What is normal colostomy & illeostomy output considered?

Colostomy: 200-600 mL Illeostomy: 500-1000 mL

Are fluid & electrolyte losses more of a concern with illestomy or colostomy?

Illeostomy ***replace fluids and electrolytes ***aim for 1L more than output

What does lower anterior resection involve

Removal of the sigmoid colon and rectum. Still has the anus thus do not need an ostomy

How is lower anterior resection syndrome characterized

increased frequency and clustering of BMs, urgency & incontinence OR constipation and feelings of incomplete emptying Very common with this procedure

Medical and nutritional recommendations for lower anterior resection syndrome

1. low fiber diet for 2 weeks post-op 2. largest meal earlier in the day 3. psyllium 4. imodium 5. serotonin receptor antagonists or bile acid sequestrants 6. Tap water enema (insitlled and help for 30 second) if OK by surgeon 7. Sacral nerve simulation if persisting > 1 year 8. Pelvic floor rehab

What is a neorectal reservoir?

Either a 1 or 2 step process used to create an internal resoirvoir using the ileum. Temporary ileostomy is reversed at 8-12 weeks post-op.

What to expect with BMs for neorectal resoivoir

5-7 loose BMs with urgency for up to 6 weeks post-op. They will become less frequent and thicken as the pouch stretches over 6 months *may need anti-diarrheals before meals

3 vitamins/minerals that may become deficient in response to rapid transit time through the GI tract

Vitamin D, calcium, B12

What is the standard of care for anal cancer?

ChemoRT. Surgery is for persistent disease