Chapter 19: GI cancers Flashcards
________ is also known as the “second brain and functions as an essential component of the immune system
Small bowel (small intestine)
Cirrhosis of the liver is associated with hepatocellular carcinoma and is often associated with (3)
Hepatitis C
Alcohol Abuse
Nonalcoholic fatty liver
Function of the bile duct
Carries bile from the liver and gallbladder to the small intestine
There are similar presenting symptoms for bile duct cancer and pancreatic cancer which include
Jaundice, acholic stools, wt loss
This is a slow growing tumor of the small bowel
neuroendocrine
Most patients with _______ cancer experience bleeding which may be mistaken for hemorrhoids
anal
This is the main subtype of colorectal cancer
adenocarcinoma
This is the most common (and deadliest) GI cancer after colorectal
Hepatocellular
These are the 4 cancer sites associated with HPV
- anal
- oral
- cervical
- esophageal
This type of GI cancer is associated w/ capsicum + other peppers and sweetened beverages
Gallbladder
These 4 types of GI cancer are more prevalent in women than men
Small bowel PET, gallbladder, anal, colorectal
Of the GI cancers, this one has the strongest relation with nutrition & lifestyle factors
colorectal
This is the greatest risk factor for anal cancer
HPV
True/false: ERAS include carb-loading
True
ERAS is aka “fast track surgery”
______ related to gastroparesis & ileus are common post-op issues that is a major cause for readmission post GI surgery
Dehydration
3 tips to reduce gas pains
Walking
Chewing gum
Heating pad
T/F: Small intestinal bacterial overgrowth may be a side effect of small bowel resection
True
*Probiotics may help to reduce the risk
What is the length requirement to define “short bowel?”
<150 cm
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
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
Medical management of enterocutaneous fistula
PPI (IV form) + anti-diarrheals
What is the Bristol scale?
A way to describe stool, 1-7
1= impacted
7= fully liquid
Is it better to titrate or hold medications to help gain control of BMs?
Titrate. Helps to prevent overcorrection and extreme swings in BMs
What is considered a low level of Vitamin B12 in the blood
<300 pg/mL
_____ 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?
- Intrahepatic - within the liver
- Perihilar - outside the liver
- Distal - closest to intestine
Whipple is the sole curative intention for ______ or ______ choliangiocarcinoma
Perihilar
Distal
Palliative intervention for choliangiocarcinoma (2)
- Bile duct stenting (improves survival, plastic < metal)
- 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
- 6 small meals/snacks with CHO rich snack at bedtime
- Minimize time without nutrition d/t decreased glycogen stores (may need dextrose containing IV)
- 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 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
- Avoid hot beverages
- 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
- low fiber diet for 2 weeks post-op
- largest meal earlier in the day
- psyllium
- imodium
- serotonin receptor antagonists or bile acid sequestrants
- Tap water enema (insitlled and help for 30 second) if OK by surgeon
- Sacral nerve simulation if persisting > 1 year
- 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
