Group Teaching - Cancers of the GI Tract Flashcards
Case 1
76-yr-old gentleman presents to GP complains of discomfort behind his sternum every time he eats, starts seconds after swallowing. He noticed this 3 months ago and it’s getting worse.
As a result, he has been eating less and less. His wife, who comes to the clinic with him, says he has lost a lot of weight, although he has not noticed.
He denies any other symptoms
* No shortness of breath, palpitations, vomiting, change in bowel habit or blood in stool.
He’s an ex-smoker (20 pack-years) with a history of mild chronic obstructive pulmonary disease, hypertension (takes one tablet) and type 2 diabetes (diet-controlled).
Lives with his wife, helps look after his grandchildren 2-3 times a week. Finding this more difficult. He needs no help with his day-to-day activities.
O/E
* 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?
Think about his recent history and current examination, get into the habit of organising your differential diagnoses into categories.
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
Case 1
76-yr-old gentleman presents to GP complains of discomfort behind his sternum every time he eats, starts seconds after swallowing. He noticed this 3 months ago and it’s getting worse.
As a result, he has been eating less and less. His wife, who comes to the clinic with him, says he has lost a lot of weight, although he has not noticed.
He denies any other symptoms
* No shortness of breath, palpitations, vomiting, change in bowel habit or blood in stool.
He’s an ex-smoker (20 pack-years) with a history of mild chronic obstructive pulmonary disease, hypertension (takes one tablet) and type 2 diabetes (diet-controlled).
Lives with his wife, helps look after his grandchildren 2-3 times a week. Finding this more difficult. He needs no help with his day-to-day activities.
O/E
* 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 else would you ask or do in clinic?
Shift through the differentials with additional history and examination.
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
Is this of oesophageal origin?
* Is food painful on swallowing? (upper)
* Is food easy to swallow but feels stuck seconds later? (lower)
Is there an mechanical or neurological cause?
* Are both solids and liquids hard to swallow (likely neurological)
If a mechanical cause, is the patient at risk of strictures?
* Ask about history of reflux
Is there blood in stool that the patient has not noticed?
* Would suggest a GI malignancy.
* Perform a digital rectal examination.
Case 1
76-yr-old gentleman presents to GP complains of discomfort behind his sternum every time he eats, starts seconds after swallowing. He noticed this 3 months ago and it’s getting worse.
As a result, he has been eating less and less. His wife, who comes to the clinic with him, says he has lost a lot of weight, although he has not noticed.
He denies any other symptoms
* No shortness of breath, palpitations, vomiting, change in bowel habit or blood in stool.
He’s an ex-smoker (20 pack-years) with a history of mild chronic obstructive pulmonary disease, hypertension (takes one tablet) and type 2 diabetes (diet-controlled).
Lives with his wife, helps look after his grandchildren 2-3 times a week. Finding this more difficult. He needs no help with his day-to-day activities.
O/E
* 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 now?
- Peptic ulcer disease
- Benign oesophageal stricture
- Achalasia
- Malignant oesophageal lesion
- Oesophageal spasm
Case 1
76-yr-old gentleman presents to GP complains of discomfort behind his sternum every time he eats, starts seconds after swallowing. He noticed this 3 months ago and it’s getting worse.
As a result, he has been eating less and less. His wife, who comes to the clinic with him, says he has lost a lot of weight, although he has not noticed.
He denies any other symptoms
* No shortness of breath, palpitations, vomiting, change in bowel habit or blood in stool.
He’s an ex-smoker (20 pack-years) with a history of mild chronic obstructive pulmonary disease, hypertension (takes one tablet) and type 2 diabetes (diet-controlled).
Lives with his wife, helps look after his grandchildren 2-3 times a week. Finding this more difficult. He needs no help with his day-to-day activities.
O/E
* 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 investigations would you request?
-
Bedside:
- ECG (are there signs of cardiac ischaemia?)
-
Blood tests:
- Full blood count (iron deficiency anaemia from chronic GI bleed?)
- Urea and electrolytes (dehydration from poor oral intake?)
-
Imaging:
- CXR (basal crepitations Rt LL)
- Microbiology: None required
-
Special/invasive:
- He qualifies for an urgent upper GI endoscopy through the 2-week-wait suspected cancer pathway.
Case 1
76-yr-old gentleman presents to GP complains of discomfort behind his sternum every time he eats, starts seconds after swallowing. He noticed this 3 months ago and it’s getting worse.
As a result, he has been eating less and less. His wife, who comes to the clinic with him, says he has lost a lot of weight, although he has not noticed.
He denies any other symptoms
* No shortness of breath, palpitations, vomiting, change in bowel habit or blood in stool.
He’s an ex-smoker (20 pack-years) with a history of mild chronic obstructive pulmonary disease, hypertension (takes one tablet) and type 2 diabetes (diet-controlled).
Lives with his wife, helps look after his grandchildren 2-3 times a week. Finding this more difficult. He needs no help with his day-to-day activities.
O/E
* 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
Further investigations:
* Urine – NAD
* WCC 9.0
* Hb 10.3 (Increased)
* K+ 3.8
* Creat 46
* INR & APTR Normal
* Bil 14
* Alb 28 (Increased)
* CRP 32
ECG – sinus tachycardia
What will the Upper GI MDT need to consider when deciding the treatment approach?
- Staging CT CAP
- PET Scan
- Staging laparoscopy
Case 2
A 68-year-old female diabetic is started on an ACE inhibitor (Ramipril) by her GP to control her hypertension.
Her doctor, knowing that ACE inhibitors may cause a deterioration in renal function, takes an initial set of blood tests. Although only kidney function is needed, he uses the opportunity to send for some other routine tests.
He aims to repeat these blood tests 7 days after Ramipril is started as a check.
The first set of blood tests comes back as follows:
* FBC: Hb 101.0 g/L, mean corpuscular volume (MCV) 72.3 fL, platelets 203, WCC 4.6
* U&Es: Electrolytes normal, Creatinine 121 μM/L
* HbA1c: 59%
What do these blood results mean?
- Hb 101.0 g/L (normal: 120-155) → Anaemia
-
Mean corpuscular volume 72.3 (80-100)
- The MCV is the size of the red blood cell
- Anaemia with low MCV is called microcytic anaemia
- Platelets 203 x103 (150-450)
- WCC 4 x103 (4.5-11.0)
-
Electrolytes normal, Creatinine 121 μM/L (45-90)
- The patient’s creatinine had not dramatically changed from a year previously.
- The slight elevation reflects a degree of chronic kidney disease, likely secondary to diabetes.
-
HbA1c: 59%
- The percentage of Hb molecules that are ‘glycosylated’ reflects blood glucose levels over a period of 3 months.
- Target for well-controlled diabetes: 48%
Case 2
A 68-year-old female diabetic is started on an ACE inhibitor (Ramipril) by her GP to control her hypertension.
Her doctor, knowing that ACE inhibitors may cause a deterioration in renal function, takes an initial set of blood tests. Although only kidney function is needed, he uses the opportunity to send for some other routine tests.
He aims to repeat these blood tests 7 days after Ramipril is started as a check.
The first set of blood tests comes back as follows:
* Hb 101.0 g/L (normal: 120-155) → Anaemia
* Mean corpuscular volume 72.3 (80-100)
* The MCV is the size of the red blood cell
* Anaemia with low MCV is called microcytic anaemia
* Platelets 203 x103 (150-450)
* WCC 4 x103 (4.5-11.0)
* Electrolytes normal, Creatinine 121 μM/L (45-90)
* The patient’s creatinine had not dramatically changed from a year previously.
* The slight elevation reflects a degree of chronic kidney disease, likely secondary to diabetes.
* HbA1c: 59%
* The percentage of Hb molecules that are ‘glycosylated’ reflects blood glucose levels over a period of 3 months.
* Target for well-controlled diabetes: 48%
A week later the patient has her follow-up GP appointment.
What would you ask and what would you do to narrow down your differential?
Any overt bleeding noticed?
* Blood in stool
* Haematuria
* Epistaxis
* Haemoptysis
Generic symptoms of malignancy?
* Weight loss, anorexia, malaise
Symptoms that might suggest colorectal cancer?
* Change in bowel habit
* Blood or mucus in stool
* Faecal incontinence
* Feeling of incomplete emptying of bowels (tenesmus)
Symptoms that might suggest an upper GI cancer?
* Dysphagia
* Dyspepsia
Is there blood in the stool or urine that the patient has not noticed?
* Perform a digital rectal examination
* Dip the urine to check for blood
Case 2
A 68-year-old female diabetic is started on an ACE inhibitor (Ramipril) by her GP to control her hypertension.
Her doctor, knowing that ACE inhibitors may cause a deterioration in renal function, takes an initial set of blood tests. Although only kidney function is needed, he uses the opportunity to send for some other routine tests.
He aims to repeat these blood tests 7 days after Ramipril is started as a check.
The first set of blood tests comes back as follows:
* Hb 101.0 g/L (normal: 120-155) → Anaemia
* Mean corpuscular volume 72.3 (80-100)
* The MCV is the size of the red blood cell
* Anaemia with low MCV is called microcytic anaemia
* Platelets 203 x103 (150-450)
* WCC 4 x103 (4.5-11.0)
* Electrolytes normal, Creatinine 121 μM/L (45-90)
* The patient’s creatinine had not dramatically changed from a year previously.
* The slight elevation reflects a degree of chronic kidney disease, likely secondary to diabetes.
* HbA1c: 59%
* The percentage of Hb molecules that are ‘glycosylated’ reflects blood glucose levels over a period of 3 months.
* Target for well-controlled diabetes: 48%
A week later the patient has her follow-up GP appointment.
On direct questioning she admits she has noticed some weight loss over the last few months, but she cannot quantify this.
She says her stool has been slightly looser, but has not checked the colour.
Examination reveals very little, until you perform a digital rectal exam - stool on the glove has blood mixed in it but there are no palpable masses in the rectum.
What is the differential diagnosis now?
- Crohn’s disease
- Ulcerative colitis
- Colorectal cancer
- Haemorrhoids
- Coeliac disease
Case 2
A 68-year-old female diabetic is started on an ACE inhibitor (Ramipril) by her GP to control her hypertension.
Her doctor, knowing that ACE inhibitors may cause a deterioration in renal function, takes an initial set of blood tests. Although only kidney function is needed, he uses the opportunity to send for some other routine tests.
He aims to repeat these blood tests 7 days after Ramipril is started as a check.
The first set of blood tests comes back as follows:
* Hb 101.0 g/L (normal: 120-155) → Anaemia
* Mean corpuscular volume 72.3 (80-100)
* The MCV is the size of the red blood cell
* Anaemia with low MCV is called microcytic anaemia
* Platelets 203 x103 (150-450)
* WCC 4 x103 (4.5-11.0)
* Electrolytes normal, Creatinine 121 μM/L (45-90)
* The patient’s creatinine had not dramatically changed from a year previously.
* The slight elevation reflects a degree of chronic kidney disease, likely secondary to diabetes.
* HbA1c: 59%
* The percentage of Hb molecules that are ‘glycosylated’ reflects blood glucose levels over a period of 3 months.
* Target for well-controlled diabetes: 48%
A week later the patient has her follow-up GP appointment.
On direct questioning she admits she has noticed some weight loss over the last few months, but she cannot quantify this.
She says her stool has been slightly looser, but has not checked the colour.
Examination reveals very little, until you perform a digital rectal exam - stool on the glove has blood mixed in it but there are no palpable masses in the rectum.
What investigations would you request?
-
Bedside:
- 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:
- She qualifies for an urgent colonoscopy through the 2-week-wait suspected cancer pathway. If this is negative, an upper GI endoscopy will be organised.
Case 2
A 68-year-old female diabetic is started on an ACE inhibitor (Ramipril) by her GP to control her hypertension.
Her doctor, knowing that ACE inhibitors may cause a deterioration in renal function, takes an initial set of blood tests. Although only kidney function is needed, he uses the opportunity to send for some other routine tests.
He aims to repeat these blood tests 7 days after Ramipril is started as a check.
The first set of blood tests comes back as follows:
* Hb 101.0 g/L (normal: 120-155) → Anaemia
* Mean corpuscular volume 72.3 (80-100)
* The MCV is the size of the red blood cell
* Anaemia with low MCV is called microcytic anaemia
* Platelets 203 x103 (150-450)
* WCC 4 x103 (4.5-11.0)
* Electrolytes normal, Creatinine 121 μM/L (45-90)
* The patient’s creatinine had not dramatically changed from a year previously.
* The slight elevation reflects a degree of chronic kidney disease, likely secondary to diabetes.
* HbA1c: 59%
* The percentage of Hb molecules that are ‘glycosylated’ reflects blood glucose levels over a period of 3 months.
* Target for well-controlled diabetes: 48%
A week later the patient has her follow-up GP appointment.
On direct questioning she admits she has noticed some weight loss over the last few months, but she cannot quantify this.
She says her stool has been slightly looser, but has not checked the colour.
Examination reveals very little, until you perform a digital rectal exam - stool on the glove has blood mixed in it but there are no palpable masses in the rectum.
Colonoscopy & Biopsy confirms adenocarcinoma of the descending colon
What will the Lower GI MDT need to consider when deciding the treatment approach?
- Staging CT CAP
- PET Scan
- Staging laparoscopy
Case 2
A 68-year-old female diabetic is started on an ACE inhibitor (Ramipril) by her GP to control her hypertension.
Her doctor, knowing that ACE inhibitors may cause a deterioration in renal function, takes an initial set of blood tests. Although only kidney function is needed, he uses the opportunity to send for some other routine tests.
He aims to repeat these blood tests 7 days after Ramipril is started as a check.
The first set of blood tests comes back as follows:
* Hb 101.0 g/L (normal: 120-155) → Anaemia
* Mean corpuscular volume 72.3 (80-100)
* The MCV is the size of the red blood cell
* Anaemia with low MCV is called microcytic anaemia
* Platelets 203 x103 (150-450)
* WCC 4 x103 (4.5-11.0)
* Electrolytes normal, Creatinine 121 μM/L (45-90)
* The patient’s creatinine had not dramatically changed from a year previously.
* The slight elevation reflects a degree of chronic kidney disease, likely secondary to diabetes.
* HbA1c: 59%
* The percentage of Hb molecules that are ‘glycosylated’ reflects blood glucose levels over a period of 3 months.
* Target for well-controlled diabetes: 48%
A week later the patient has her follow-up GP appointment.
On direct questioning she admits she has noticed some weight loss over the last few months, but she cannot quantify this.
She says her stool has been slightly looser, but has not checked the colour.
Examination reveals very little, until you perform a digital rectal exam - stool on the glove has blood mixed in it but there are no palpable masses in the rectum.
Colonoscopy & Biopsy confirms adenocarcinoma of the descending colon
How would you manage this case?
- Palliative chemotherapy
- Palliative care
- Resect the colonic primary & liver metastases straight away
- Colonic stent then neoadjuvant chemotherapy
- Resect primary colonic tumour, followed by neoadjuvant chemotherapy, followed by liver resection
