GI15 - GI Malignancy

Question 1

Dysphagia

Oesophageal Dysphagia
Oropharyngeal Dysphagia
Malignant Dysphagia
Other Red Flag Symptoms

Answer 1

1. ) Oesophageal Dysphagia - food stuck in the throat
   - obstruction: tumour, stricture, inflammation, can be classed as extraluminal, intraluminal, or luminal
   - neuromuscular: presbyoesophagus (abnormal shape), achalasia, dysmotility
   - OGD used to exclude obstructive causes
   - barium swallow or manometry for neuromuscular
2. ) Oropharyngeal Dysphagia - food can’t enter throat
   - problems with tongue muscle coordination
   - often as a result of neurological disease e.g. stroke
   - video-fluoroscopy can be used to assess swallowing
   - may need enteral feeding tube if unsafe swallowing

3.) Malignant Dysphagia - usually squamous cell carcinoma or adenocarcinoma.

4. ) Other Red Flag Symptoms - ALARM
   - Anaemia, Loss of Weight, Anorexia, Recent onset of progressive symptoms, Masses/Malaena

Question 2

5 causes of epigastric pain with bleeding

Type of Bleeding

Answer 2

1. ) Bleeding - malaena or haematemesis
   - red flag symptom of gastric cancer (carcinoma)

2.) Other Causes - oesophageal varicies, acute gastritis, gastric or duodenal ulcers

Question 3

3 cancers that can occur in the stomach

Type of Cancer
Risk Factors
Prognosis

Answer 3

1. ) Gastric Cancer - adenocarcinomas typically in the cardia or antrum so may cause epigastric pain (similar pain to peptic ulcers) but may have a palpable mass
   - risk factors: smoking, FH, high salt diet, H. pylori
   - poor prognosis (10%) but no screening in UK (rare)
2. ) Gastric Lymphoma - associated w/ H. pylori and affects mucosa associated lymphoid tissue (MALT)
   - presents like gastric cancer but has better prognosis
3. ) GI Stromal Tumours (GISTs) - usually benign sarcomas
   - tend to be an incidental finding on endoscopy

Question 4

4 features of cancers of the liver

Primary Malignancy
Liver Metastases x5
3 Ways of Metastatic Spread
Jaundice (red flags x4)

Answer 4

1. ) Primary Malignancy - very rare
   - hepatocellular carcinoma, links to underlying disease
2. ) Liver Metastases - very common
   - entire GI tract drains into the portal system so any malignant cells go through the liver
   - bowel, pancreas, stomach, breast, lung
3. ) 3 Ways of Metastatic Spread
   - haematogenous: portal system
   - lymphatics: common in carcinomas
   - transcoelomic: ovarian, breast, lung
4. ) Jaundice - hepatic or post-hepatic
   - red flags: hepatomegaly (irregular border), weight loss, painless, ascites

Question 5

4 features of pancreatic cancer

Type of Cancer
Presentation
Risk Factors x5
Prognosis

Answer 5

1.) Type of Cancer - 80% are ductal adenocarcinomas

2. ) Presentation - depends on location on pancreas
   - head: obstructive jaundice (blocks biliary tree)
   - body/tail: vague symptoms, affects pancreas function
3. ) Risk Factors - age (>60), male, smoking, FH, chronic pancreatitis
4. ) Prognosis - very poor

Question 6

3 key symptoms of lower GI (bowel) malignancy

Obstruction
Per Rectum Bleeding (other causes x5)
Change in Bowel Habit
Other Red Flags x4

Answer 6

1. ) Obstruction
   - causes abdominal pain or distension
   - nausea/vomiting (SI), constipation (LI)
2. ) Per Rectum Bleeding - haematochieza or malaena
   - benign causes: haemorrhoids, anal fissure, UC, diverticular disease, infective gastroenteritis
3. ) Change in Bowel Habit - frequency, consistency, associated symptoms (bloating etc)
   - benign causes: diet, intolerance, IBD, IBS, medication, thyroid disorders
4. ) Other Red Flags - 3 key symptoms plus:
   - age: over 50
   - iron deficient anaemia: slow bleeding of malignancies
   - tenesmus: needing to evacuate but cannot
   - unexplained weight loss

Question 7

Large and small bowel cancer

Type of Cancer
Risk Factors

Answer 7

1. ) Large Bowel Cancer - adenocarcinoma
   - normal mucosa –> adenoma –> adenocarcinoma
   - risk factors: FH, polyposis (FAP, HNPCC), UC, Peutz-Jeghers syndrome
2. ) Small Bowel Cancer - 5 different types (stromal, lymphoma, adenocarcinoma, sarcoma, carcinoid)
   - risk factors: diet, coeliac’s, IBD, FAP
   - abdominal pain more likely in small bowel cancer

Question 8

General management of GI malignancies

Duke’s Staging
Investigations
Treatment

Answer 8

1. ) Duke’s Staging - stages A-D, using staging CT
   - A: confined to bowel wall, B: through the bowel wall
   - C: affected lymph nodes, D: distant metastases
2. ) Investigations - blood test (FBC, tumour markers), CT/MRI, endoscopy/colonoscopy
   - colorectal cancer: CT of chest, abdomen and pelvis

3.) Treatment - chemotherapy, radiotherapy, surgical resections

Question 9

Right vs left sided colon cancer

Bowel Obstruction
Bleeding
Change in Bowel Habit
Mass Location
Growth
Presentation

Answer 9

1.) Bowel Obstruction - more common in LS because it is narrower so symptoms appear earlier

2. ) Bleeding - LS has visible mixed PR bleeding
   - RS only has occult bleeding (needs to be tested)
3. ) Change in Bowel Habit - occurs earlier in LS
   - LS has tenesmus

4.) Mass Location - right iliac fossa vs left iliac fossa

5. ) Growth - both grow slowly
   - LS is stenosing (inwards, applecore sign)
   - RS is fungating (grows like polyps)
6. ) Presentation - RS more advanced when caught because the symptoms appear later
   - RS often just presents with anaemia and mass on examination
   - LS present with mixed PR bleeding and change in bowel habit