Session 8 Flashcards
How common are GI malignancies? How do we categorise their symptoms?
Bowel is 4th most common cancer (excluding prostate and breast cancer (sex specific))
Upper GI: dysphagia, epigastric pain and jaundice
Lower GI: bowel obstruction, perirectal bleeding and change in bowel habit.
What is dysphagia and what are its differentials?
Difficulty swallowing
Extraluminal - coming in from outside - growths or compressions of oesophagus e.g. from heart/lung pathologies
Luminal - wall of lumen - malignant causes/outgrowth of wall
Intraluminal - within lumen itself - strictures, foreign bodies
Benign
Malignant: ◦ Squamous cell carcinoma ◦ Adenocarcinoma
Red flags of dysphagia?
ALARM
Anaemia
Loss of weight (unintentional)
Anorexia - loss of appetite
Recent onset of progressive symptoms
Masses/Malaena
Summarise oesophageal carcinoma?
General point:
◦ Type of carcinoma is linked to the epithelial type
◦ i.e. Stratified squamous epithelium in the oesophagus -> squamous cell carcinomas
◦ Everywhere else in GI tract columnar epithelium -> adenocarcinomas
Therefore most malignancies in the oesophagus are squamous cell carcinoma
Lower third can develop adenocarcinoma from Barrett’s
Typically present with progressive dysphagia
◦ Spread is common if presenting with symptoms as symptoms present when its become advanced.
Risk factors: Smoking, Barrett’s
Barium swallow can be used to view stricture/obstruction,
OGD/endoscopy can also be used
Prognosis: Poor ◦ 5% survival at 5 years
What are the quadrants of the abdomen? Name some causes of pain in each region.
Red flags of epigastric pain?
Malaena
◦ Altered blood coming from the upper GI tract
Haematemesis
Summarise gastric cancer
Typically in the cardia or antrum
◦ Adenocarcinomas - Present with similar pain to peptic ulcer
◦ 50% have a palpable mass!
Risk factors ◦ Smoking, high salt diet, family history, H. Pylori
Use of refrigerators means less salt used to preserve food so gastric cancer less likely.
General note: Chronic inflammation puts you at higher risk of malignancy
Prognosis generally poor ◦ 10% 5 year survival ◦ 50% after ‘curative’ surgery
Role of screening - done more in Asian countries as more prevalent. not done in UK as not common.
Other cancers that can occur in the stomach:
Gastric lymphoma
◦ MALT (mucosal associated lymph tissue) tissue
◦ Similar presentation to gastric carcinoma ◦ Most associated with H. pylori
◦ Prognosis much better than gastric cancer
Gastrointestinal stromal tumours (GISTs)
◦ Sarcomas (not epithelial)
◦ Tend to be an incidental finding on endoscopy nearly always benign but removed for safe measure as can turn malignant.
Jaundice red flags?
Hepatomegaly - Irregular border - indication of malignant rather than benign - described as craggy
Unintentional weight loss
Painless Ascites - from liver damage causing low albumin, compression causing portal hypertension, if malignant can get deposits in peritoneum which dysregulate absorption causing ascites.
Why is it common for cancer to reach the liver?
Primary malignancy very rare
◦ Hepatocellular carcinoma
◦ Typically links to underlying disease caused by chronic inflammation.
Think about the portal system
◦ Drains the entirety of the GI tract
◦ Any malignant cells go through the liver
◦ Therefore it is a common site for metastases
Method of spread:
Haematogenous spread:
◦ Portal spread
Lymphatics:
◦ Common in carcinomas
◦ Sentinel lymph node
Spread common from other systems:
◦ Ovarian - Transcoelomic
◦ Breast
◦ Lung
How does pancreatic cancer develop? What are its risk factors?
Presentation:
◦ Head: Jaundice/abnormal LFTs
◦ Body/tail: Symptoms more vague; relate to function of pancreas e.g. steatorrhea
◦ 80% ductal adenocarcinomas
Risk factors: ◦ Family history, smoking ◦ Men affected more than women, incidence increases with age (typically >60yrs) ◦ Chronic pancreatitis
Prognosis very poor as symptoms present when cancer is advanced
What are the symptoms obstruction and their differential diagnosis? Red flags?
General Symptoms: ◦ Abdominal distension ◦ Abdominal pain Obstruction measured by looking at dilation of bowel, normal limits up to for: small bowel 3cm, large bowel 6cm and caecum 9cm.
Differential diagnosis:
Benign:
◦ Volvulus ◦ Diverticular Disease ◦ Hernias ◦ Strictures ◦ Intussusception - where one potion of bowel slides into another region causing obstruction. ◦ Pyloric stenosis - often in babies causing projectile vomiting
Malignant: ◦ Small vs large bowel cancer
Red flags: ◦ Unintentional weight loss ◦ Unexplained abdominal pain
How does obstruction present differently between small and large bowel?
If obstruction is in small bowel then nausea/vomiting presents early because contents can’t get passed so will go back up the way they came
If obstruction is in large bowel then constipation (absolute - gas and faeces) will present early because flow won’t be an issue as it will take a while to build up but patient won’t be able to pass the faeces/gas.
Differentials for PR bleeding and red flags. How is colour of blood relevent?
Differential diagnosis:
Benign o Haemorrhoids o Anal fissures o Infective gastroenteritis o Inflammatory bowel disease o Diverticular disease
Malignant o Small vs large bowel cancer…
Nature of bleeding:
Fresh, bright red blood indicates lower down.
Malaena would indicate higher GI bleeding.
Red flags:
Age dependent
Iron deficient anaemia
Unexplained weight loss
Change in bowel habit
Tenesmus - sensation of needing to evacuate bowels, going to the toilet and not feeling like they’ve been emptied
Change in bowel habits? Differential diagnosis, associated symptoms and red flags?
Change in frequency ◦ Diarrhoea? ◦ Constipation?
Change in consistency ◦ More watery? Associated symptoms?
◦ Bloating
◦ Abdominal discomfort
Differential diagnosis:
Benign -
o Thyroid disorder
o Inflammatory bowel disease
o Medication related
o Irritable bowel syndrome
o Coeliac disease
Malignancy Red flags:
Age dependent
Iron deficient anaemia
Unexplained weight loss
PR blood loss
Large bowel cancer
Adenocarcinoma
Third commonest cancer in the UK (excluding breast and prostate)
Risk factors include
o Family history
o Inflammatory bowel disease
o Polyposis syndromes e.g. FAP, HNPCC
o Diet and lifestyle
Screening: Faecal Occult Blood Samples
How do polyps develop to adenocarcinoma?
How does large bowel cancer differ from left to right sided?
Stenosing gives apple-core like X-ray
General principles of management for GI cancer?
TNM staging - look at image
Dukes staging - bowel cancer
Dukes’ A - cancer is confined to inner lining of mucosa of bowel
Dukes’ B - progresses to affect musculature of bowel wall
Dukes’ C - Same as B but lymph nodes also affected
Dukes’ D - B and C but with metastatic spread.
General management:
TNM staging
Blood test- FBC, tumour markers (e.g. CEA (bowel cancer), CA 19-9 (pancreatic cancer))
CT/MRI Endoscopy/Colonoscopy
o Capsule endoscopy
Treatment o Chemotherapy o Radiotherapy o Surgical resections
