GI Flashcards
What type is oesophageal cancer?
It is an adenocarcinoma if it affects the lower 1/3 of the oesophagus and the squamous cell carcinoma if it affects the upper 2/3
What are the risk factors for oesophagus cancer?
CHRONIC GORD Excessive Smoking or alcohol Age Obesity Baretts oesophagus Chronic achalasia (weakness of oesophageal sphincter) Plummer vinson syndrome Being male Diet high in fats or nitroamines
What is baretts oesophagus?
This is metaplasia of the cells of the lower 1/3 of the oesophagus from squamous cells to simple columnar cells.
How should people with barretts oesophagus be treated?
As they are at high risk of developing of oesophageal cancer…
They should have surveillance- endoscope with biopsies every 2-3 years
And PPI
What is chronic achalasia?
Dysfunction of the lower oesophageal sphincter which means it can’t relax, this causes a functional stenosis/ narrowing and leads to dysphagia of both liquids and solids, as well as heartburn and regurgitation of food.
What is plummer vinson syndrome?
Triad of dysphagia due to the formwtion of oesophageal webs, glossitis and iron deficiency anaemia.
What are the symptoms of oesophageal cancer?
Progressive dysphagia Upper abdo pain Dyspepsia Anorexia Weight loss Hoarseness of voice Cough Nausea and vomiting Odynophagia Reflux
What is the 2WW criteria in terms of Oesophageal cancer?
OGD within 2/52 if the patient has dysphagia
Or
If the patient is > or equal to 55 and has upper abdominal pain/reflux or dyspepsia
What investigations are done for oesophageal cancer?
OGD
If oesophageal cancer is confirmed on the OGD, then a staging CT CAP will be performed
If there is no mets then an endoscopic USS can be performed for local staging
If there are mets then a staging laparoscopy can be performed
If there are palpable lymph nodes then fine needle aspiration should be carried out
If there is haemoptysis/hoarseness of voice then a bronchoscopy should be performed to look for local invasion
What is the management of oesophageal cancer?
It is often found when it is advanced therefore palliative treatments like stenting and nutritional inputs (PEG/ RIG tubes), photodynamic and analgesia.
The curative treatment is surgery, which may be performed alongside radiotherapy or chemoradiotherapy
Surgery=
an oesophagectomy – your surgeon removes the part of the oesophagus containing the cancer
a total oesophagectomy - your surgeon removes your whole oesophagus
an oesophago-gastrectomy – your surgeon removes the top of your stomach and the part of the oesophagus containing cancer
What is the surgery to remove part of the oesophagus and stomach in oesophageal cancer, associated with?
It is associated with an anastomotic leak.
What are the other causes of dysphagia?
Mechanical obstruction- stomach cancer, strictures, enlarged lymph nodes
Neuromuscular causes- achalasia
What are the risk factors for gastric cancer?
FHx Age Male Diet- excess salts, spicy food, excess alcohol, nitrates Gastric adenomatous polyps H pylori infection Pernicious anaemia Group A blood
What are the symptoms of gastric cancer?
Early satiety
Dysphagia
Dyspepsia
B symptoms
Reflux
Epigastric pain
N and V
What may you find on examination of a patient with gastric cancer?
Epigastric mass Palpable virchows node (left supraclavicular lymph node) Hepatomegaly Ascites Jaundice Acanthosis nigricans
Gastric cancers typically spread to the liver, which is why signs of liver failure may be present oxamination.
How do you diagnose gastric cancer?
OGD and biopsy
The tissue from the biopsy is sent for:
- CLO testing (check for H pylori)
- histology
- receptor testing (ie: HER2 which checks whether or not MAB can be used)
What investigations are done after GI cancer is diagnoses?
CT CAP
Staging laparoscopy
+/- PET CT
How do you treat gastric cancer
Most patients are treated with palliative care
- targeted therapy and chemotherapy
- all patients must also be offered nutritional support and a MUST score should be calculated
- a dietitian review should take place and a PEG tube should be enough to ensure adequate nutrition
Curative treatment is with surgery
Total gastrectomy if the cancer is proximal or partial gastrectomy if the cancer is distal
+ lymphadenectomy and chemo pre and post op
What are the complications of gastrectomy?
Dumping syndrome B12 deficiency Iron deficiency Malnutrition Death Anastomotic leak Re operation
What is dumping syndrome?
Where food contents move too quickly into the small intestine resulting in fluid shift and nausea, vomiting, palpitations, sweating p, bloating, cramping, diarrhoea, dizziness, fatigue soon after eating a meal.
Late dumping syndrome= this occurs 2-3 hours after eating a meal, this is where there is a surge of insulin after eating foods high in glucose, resulting in hypoglycaemia.
What are the differentials for gastric cancer?
Peptic ulcer disease
GORD
Gallstones
Pancreatic cancer
What type of cancer is colorectal cancer?
It is normally adenocarcinoma
What are the risk factors for developing colorectal cancer?
Family Hx Male Increasing age Smoking UC Lynch disease (HNPCC) Familial adenomatous polyps Diet- excess alcohol, processed meat, decrease in fibre
What is FAP (familial adenomatous polyps)?
This is an autosomal dominant mutation of the APC gene
If untreated then all patients will go on to develop cancer by the age of 40.
How do patients with colorectal cancer present?
Weight loss Abdominal pain Rectal bleeding Change in bowel habit Bowel obstruction Iron deficiency (tiredness and SOB on exertion) Tenesmus (incomplete emptying)
When is an urgent referall recommended for colorectal cancer?
If the patient is 40 years or over with unexplained weight loss and abdominal pain
If the patient is 50 yers or over with unexplained rectal bleeding
If the patient is aged 60 years or over with iron deficiency anaemia and a change in bowel habit
If the patient has tested positive for faecal occult blood
Consider an urgent referall in
What is stage 0 in colorectal cancer?
Cancer in situ
What staging is used for colorectal cancer?
Dukes staging
What is stage 2 of colorectal cancer.
The cancer has grown through the muscle layer of the colon and may involve nearby tissue but does not involve nearby lymph nodes or distant mets
What is HNPCC?
Lynch disease
Autosomal dominant mutation DNA mismatch repair
What are the inherited causes of colorectal cancer?
FAP (affect younger people)
HNPCC (affects older)
Familial colorectal cancer (if patients dont have FAP/HNPCC
Some patients have both mutations and have FAP and HNPCC
IBD- UC/ crohns
What lifestyle factors lead to colorectal cancer?
Western diet
Low fibre, high gat
Red /processed meat
Garlic milk and calcium may be protective
Overweight
Increased exercise is protective
Depending on the area of the colorectal cancer, the presentation may be different, explain how…
If the right colon is affected…
. Weight loss, weakness, rarely obstruction
. Iron deficiency anaemia
If the left colon is affected... . Constipation . Abdo pain . Decreased stool calibre . Alternating bowel habit . Rectal bleeding . Bright red PR bleeding . LBO
If the rectum is affected... . Obstruction . Tenesmus . Bleeding . Palpable mass on PR
Why is it important to check U and Es in cancers?
Degree of dehydration
Treatment
Whether it has spread to kidney and causing problems
Why are LFTs important to test in terms of colorectal cancer?
Clotting factors are also important to check
Liver is the first place that colorectal cancer spreads to
What is the gold standard investigation for colorectal cancer?
Colonoscopy +/- biopsy
What can you use if colonoscopy can’t be used to diagnose colorectal cancer?
Flexible sigmoidoscopy
Other options;
Barium enema
CT colonography
However if they show signs of colorectal cancer you do need biopsy and you would need to do biopsy.
What can you use if the cancer is only in the rectum?
Radiotherapy
Do many patients with colorectal cancer have surgery?
No because only 10-15% are eligible
What is meant by palliative treatment?
May not cure the cancer but will improve QOL by reducing the symptoms and prolong life.
Ie: in colorectal cancer, palliative chemotherapy will be used to shrink tumours if they have small bowel obstruction, unfortunately they still only have 21 month life expectancy after this :(
What are the 4 main resections for colorectal cancer?
Right hemicolectomy
Extended right hemicolectomy
Left hemicolectomy
Anterior resection
Liver mets are the most common mets in colorectal cancer, what treatments can be done for this?
Surgical resection Microwave ablation Radiofrequency ablation Radiofrequency assisted liver resection Selective internal radiation therapy
Important to treat because they can go into liver failure which is very hard to treat
Give examples of chemotherapy and biological agents used in colorectal cancer…
Chemo=
5-fluorouracil
Capecitabine
Biological agents=
Cetuximab
Panitumumab
What are the SES of chemotherapy?
Myelosuppression (bone marrow suppresion)
Mucositis (inflammation of the mucous membranes- mainly affecting oral mucosa and oesophagus)
Methotrexate commonly causes mucositis
Peripheral neuropathy
Neutropenic sepsis (neutrophil count is below 1)
Nausea
Vomiting
Diarrhoea
Cardiotoxicity (oxolaplatin causes coronary artery vasospasm- increased Risk of MI)
Hand foot syndrome
Blood clots
Lethargy
Hypertension
Proteinuria
What is the second most common cause of cancer deaths?
Blood clots
PEs can often be an incidental finding
What are the side effects of cetuximab/panitumab?
Skin toxicity- acneform rash, dry skin Hair growth disorders- male pattern baldness or female Pruritus Nail changes Fatigue Allergic reaction Flu like symptoms Abnormal LDTs Myelosuppression Diarrhoea Nausea
What is stage 4 of the dukes staging?
The cancer has spread to regional lymph nodes but has not metastasised
What is stage 1 of colorectal carcinoma?
Cancer has grown through the mucosa and invaded the muscular layer, however no spread to nearby tissue or lymph nodes.
What is stage 2 of colorectal cancer?
This is where the colorectal cancer has gone through the mucosa and invaded the muscular layer and nearby tissue, doesn’t affect nearby lymph nodes or distant mets.
What is stage 3 of colorectal cancer?
Cancer has spread to regional lymph nodes but not metastasised.
What is the aetiology behind colorectal cancer?
- Normal colon epithelial cells
Then you get loss of tumour suppressor gene APC - Small benign growth
- Larger benign growth
- Malignant tumour (carcinoma)
