*Oesophageal and Stomach Disorders (lectures 1 and 2)

Question 1

What are the 2 possible types of oesophageal cancer?
What is the most common?
Where is each more likely to occur?
what are the main things that increase the incidence of each type?

Answer 1

Adenocarcinoma (distal oesophagus) - more common - GORD

Squamous cell carcinoma (proximal oesophagus) - smoking and drinking

Question 2

signs and symptoms of oesophageal cancer? (8)

Answer 2

dysphagia:
where the patient feels food sticking isn't necessarily where the tumour is
odynophagia
upper GI haemorrhage
anaemia
weight loss
retrosternal pain
if upper tumour, cough and hoarseness

Question 3

What should be performed if you suspect oesophageal cancer? e.g. presence of dysphagia

Answer 3

An urgent upper GI endoscopy

Also perform a colonoscopy if the patent presents with anaemia

Question 4

What 3 things should be done to help choose treatment for oesophageal and gastric cancers?

Answer 4

Determine treatment intent
Assess patient fitness
Accurate staging

Question 5

What is performed to accurately stage an oesophageal cancer?

Answer 5

CT thorax/ abdomen - if normal perform tests below
CT/PET, EUS, Laparoscopy (can spread intra-abdominally causing little seedlings in the abdomen - laparoscopy searches for this)
search hard for metastatic disease
if metastases present = palliative care

Question 6

Palliative treatment options for oesophageal cancer? (3)

Answer 6

Chemotherapy
Radiotherapy
Stenting - not very pleasant to swallow with

Question 7

Treatment options for oesophageal cancer that can be potentially cured?

Answer 7

Surgery with or without NAC - offers better cure rates for early disease
Radical chemoradiotherapy - complications are more manageable

Question 8

What are the adverse prognostic factors for oesophageal cancer? (3)

Answer 8

Oesophageal obstruction
Tumour longer than 5cm
Metastatic disease

Question 9

Staging of oesophageal cancer using TNM?

Answer 9

Tis = carcinoma in situ
T1 = invading lamina propria/ submucosa
T2 = invading muscularis propria
T3 = Invading adventitia
T4 = invasion of adjacent structures
Nx = nodes cannot be assessed
NO = no node spread
N1 = regional node metastasise 
M0 = no distant spread
M1 = distant metastasis

Question 10

What types of gastric cancers do you get? (5)

What is the most common type?

Answer 10

Adenocarcinoma - commonest type
Rarer:
lymphoma - better prognosis
Gastrointestinal Stomal Tumours - rarely metastasise = better prognosis
Squamous cell carcinoma 
Neuroendocrine tumours

Question 11

Signs and symptoms of gastric cancer? (10)

Answer 11

Dysepsia
Upper GI bleeding
Anaemia
weight loss
Abdominal mass
Anorexia/ early satiety
vomiting
Hepatomegaly
jaundice
ascites

Question 12

How do you accurately stage a gastric cancer?

Answer 12

CT thorax/ abdomen

Laparoscopy/ EUS

Question 13

Palliative treatment for gastric cancer? (3)

Answer 13

Chemotherapy
Radiotherapy
Surgical palliation e.g. for obstruction
(Trastuzamab for Her-2 positive tumours)

Question 14

Treatment for potentially curable gastric cancer?

Answer 14

surgery with or without NAC
surgery based treatment is the only potentially curative option
radiotherapy is not a treatment option for gastric cancers as the stomach is too big an organ and therefore you would poison the patient with radiotherapy

Question 15

Adverse prognostic factors for gastric cancer (6)?

Answer 15

metastatic disease
short history
advanced age
proximal lesions 
locally advanced lesion
superficial gross appearance (limits plastica)

Question 16

What is gastro-oesophageal reflux disease?

Answer 16

Reflux of stomach contents which causes troublesome symptoms and/or complications

Question 17

What causes GORD? (3)

Answer 17

Lower oesophageal sphincter doesnt work properly
Increase in intra-abdominal pressure
Gastric acid hyper secretion

Question 18

What type of people have a higher chance of getting GORD? (4)

Answer 18

Pregnant people
Obese people
Smokers
Increased association with alcohol

Question 19

Symptoms of GORD?

Answer 19

Heartburn (burning retrosternal discomfort after meals, lying, stooping or straining)
belching
acid brash (acid/ bile regurgitation)
Waterbrash (increased salivation)
odynophagia (pain on swallowing e.g. from oesophagitis)
nocturnal asthma
chronic cough
laryngitis
sinusitis

Question 20

Complications of GORD?

Answer 20

Oesophagitis
Ulceration
Benign stricture
Iron-deficiency
Barrett’s oesophagus = increased chance of oesophageal cancer

Question 21

What type of classification is used to classify GORD?

Answer 21

Los Angeles Classification

Question 22

Loss Angeles Classification?

Answer 22

“mucosal break” = a well-demarcated area of slough/ erythema) - used to encompass the old terms ulceration and erosion
1 = more than or equal to 1 mucosal break, 5mm long but not extending beyond 2 mucosal fold tops
3 = mucosal break continuous between the tops of 2 or more mucosal folds but which involves less than 75% of the oesophageal circumference
4 = mucosal break involving greater than or equal to 75% of the oesophageal circumference

Question 23

Treatments fo GORD?

Answer 23

Physically repair the defective valve (surgery)
H2 receptor antagonists
PPIs
Anti-acids

Question 24

What causes achalasia?

Answer 24

Lower oesophageal sphincter fails to relx

Question 25

Symptoms of achalasia? (4)

Answer 25

Dysphagia
regurgitation
Substernal cramps
Weight loss

Question 26

Diagnosis of achalasia?

Answer 26

CXR (fluid level in dilated oesophagus)
Barium swallow (dilated tapering oesophagus

Question 27

Treatment of achalasia?

Answer 27

endoscopic balloon dilation
Heller’s Cardiomyotomy
then PPRI
Botulinum toxin injections (non-invasive - required every few months)
calcium channel blockers and nitrates also relax the sphincter
long standing achalasia may cause oesophageal cancer