Week 17 - Oesophageal Cancer Flashcards
what do patients with symptoms suspicious of cancer get
a two week wait referral for further investigation
what can primary care refer for
an urgent direct-access endoscopy
what are the key red flags to look out for for oesophageal cancer
Dysphagia (difficulty swallowing) at any age gets an immediate two week wait referral
Aged over 55 (this is generally the cut-off for urgent versus routine referrals)
Weight loss
Upper abdominal pain
Reflux
Treatment-resistant dyspepsia
Nausea and vomiting
Upper abdominal mass on palpation
Low haemoglobin (anaemia)
Raised platelet count
what are the four types of oesophageal tumour
adenocarcinoma,
squamous cell carcinoma, leiomyoma
and squamous papilloma
what is the most common form of oesophageal cancer
squamous cell and adenocarcinoma
what is the male to female ratio for oesphageal tumours
2:1
what certain foods can predispose to squamous cell oesophageal cancers
cereals, and foods containing nitrous amides
where is squamous cell oesphageal cancer most commonly seen
the upper 2/3 of the oesophagus
where is adenocarcinomas found
in columnar epithelium and thus is strongly associated with Barrett’s oesophagus
why have oesophageal adenocarcinomas risen greatly in past few decades
due to increase in obesity and therefore increase in GORD
what is the most common presentation of adenocarcinoma
white, middle aged male
where are adenocarcinomas usually found
the lower 1/3 of the oesophagus
what are the clincial features of oesophageal carcinoma
disease is often very advanced by the time of symptomatic presentation:
- feeling lump in the throat not associated with eating
- dysphasia
- progressive dysphagia - characteritstic symptom
- weight loss and anorexia
- lymph nodes - Virchow’s node
what is the investigation of choice for oesophageal carcicnomas
endoscopy - 90% of oesophageal tumours can be imaged
what are oesphageal tumours staged using
the TNM staging system
what are the two treatment options for oesophageal cancer
surgery or palliative treatments
what is the 5 year survival rate for oesophageal cancers from presentation
5-9%
what does palliative treatment involve
stenting to allow swallowing
intubation to allow adequate nutritionb
how do most patients with oesophageal cancer die
bronchopneumonia as a result of aspiration due to dysphagia or oesophageal-broncho fistulas
what is leiomyoma
a benign tumour of the smooth muscle
may cause obstructive symptoms
is large – >5cm, in which case they can be removed surgically
what is a squamous papilloma
caused by the HPV, they are benign and VERY rare
what are the three main contribuatory factors to squamous cell carcinoma
smoking, alcohol and diet
what are papillomas particularly related to
cervical cancers
what percentage of people with Barrett’s have adenocarcinomas
13%
can a barium swallow tell u if a narrowing is due to a malignancy or not
no
what chemotherapeutic agents can you give for oesophageal cancer
cisplatin or 5-flurouracil
what is the differential diagnosis for dysphagia
- Gastro-oesophageal reflux
- Hiatus hernia
- Oesophageal cancer
- Oesophageal candidiasis
- Achalasia
- Muscle tension dysphagia
- Diffuse oesophageal spasm
- Pharyngitis
- Other neurological disorders such as cerebrovascular accidents (CVAs)
what is odynophagia
pain on swallowing
where are oesophageal cancer rates the highest
across eastern Asia
what is the most prevalent type of oesophageal cancer in the developing world
oesophageal adenocarcinomas - approx 70%
what kind of cancer are gastric cancers usually
predominantly adenocarcinomas
Barrett’s oesophagus is:
premalignant and metaplsia
what is Virchow’s node and in what cancer is it usually found
left sided supraclavicular node that is related to gastric cancer
what are peptic ulcers
a break in the mucosal lining of the stomach, with depth to the submucosa
result from an imbalance between factors promoting mucosal damage and those promoting gastroduodenal defence
what are the most common causes of gastric ulcers
the use of NSAIDs and h.pylori
what ulcers are relieved by eating
duodenal
what is a Mallory-Weiss tear
commonly presents with haematemesis after an episode of forceful or recurrent retching, vomiting, coughing or straining
what is the most common cause of a mallory weiss tear in women of childbearing age
hyperemesis gravidarum.
wha are oesophageal varices and what causes them
dilated collateral blood vessels that develop as a complication of portal hypertension.
the bleeding carries significant morbitity and mortality
what is the treatment for h pylori
PPI and two antimicrobials
what do patients have to do before being tested for h pylori
patients need to have stopped any PPI treatment at least 2 weeks prior to h pylori testing
what do haematemesis and malena suggest
an upper GI bleed
how and why does terlipressin work for variceal bleeds
terlipressin acts on the splanchnic circulation to reduce pressure in the portal vein which will help to slow or stop bleeding varices
what are the endoscopic treatment options for variceal bleeds
Firstly, bands can be used to cut off blood supply around varices.
If this is unsuccessful a procedure called trans-jugular intrahepatic portosystemic shunt (TIPS) can be used. During this procedure, an interventional radiologist will insert a stent to connect the portal vein to the hepatic vein. This allows blood to be brought back from the bowel to the heart and can bypass the liver thus reducing pressure in the portal vein. This will work in a similar
what are the endoscopic treatment options for a peptic ulcer bleed
adrenaline
clip
thrombin
heat probe
what is the Rockall scoring system used to estimate
used to estimate the risk of rebleeding and of overall mortality from an upper GI bleed
A 60-year female presents to her GP with weight loss. On taking a detailed history her GP notes that she has been taking omeprazole 20 mg orally daily for 5 years now due to acid reflux. She has also noticed pain just below her sternum. She finds that the pain is nearly constantly present and feels like a burning sensation. This does not settle when she is eating food. Which of her symptoms indicate that she may have gastric cancer rather than any other upper GI pathology?
stomach pains
A 59-year-old male presents to the GP with concerning features of GORD. On further questioning, he has lost around 4kg of weight unintentionally. As per NICE guidance, the GP refers the gentleman under a 2 week wait Upper GI clinic for them to perform an endoscopy. During the endoscopy, histology samples are taken of a suspicious lesion found in the lower 1/3 of the oesophagus. This demonstrates Barrett’s oesophagus. Which cancer does this predispose an individual to?
Oesophageal adenocarcinoma
A 79-year-old lady attends A and E. She was reviewed by her GP earlier in the day due to possible brown vomit. The GP was unsure if the lady suffered an upper GI bleed however it was decided that she would likely require admission. Which scoring system would allow you to decide if the patient would be able to go home and what score would indicate this?
Glasgow Blatchford <1
A 64-year-old man attends A and E with dark black stools. He feels dizzy and appears to be breathless. His blood tests come back with a raised urea and low haemoglobin. Which possible features in his history would suggest that he is suffering from a variceal bleed?
Alcoholic liver disease
A 65-year-old lady attends A and E following multiple episodes of fresh red blood in her vomit. She has a complex past medical history including rheumatoid arthritis (RA), depression, osteopenia, GORD, and previous ectopic pregnancy. She has been taking several medications over the counter, as well as prescribed medications for a recent flare of her RA symptoms. Which of the following medications is least likely to be contributing to her upper GI bleed?
Colecalciferol
what is Barrett’s oesophagus
refers to when the lower oesophageal epithelium changes from squamous to columnar epithelium.
what is this process called
metaplasia
what kind of condition is Barrett’s oesophagus
a premalignant condition and significant risk factor for developing adenocarcinoma
what is Zollinger-Ellison syndrome
a rare condition where a duodenal or pancreatic tumour secretes excessive quantities of gastrin
what is gastrin and what does excess of this result in
Gastrin is a hormone that stimulates acid secretion in the stomach. Therefore, there is excess production of stomach acid, resulting in severe dyspepsia, diarrhoea and peptic ulcers.
what are gastrinomas associated with
Gastrin-secreting tumours (gastrinomas) may be associated with multiple endocrine neoplasia type 1 (MEN1), an autosomal dominant genetic condition, which can also cause hormone-secreting tumours of the parathyroid and pituitary glands.
what are the signs of an upper gastrointestinal bleed
Haematemesis (vomiting blood)
Coffee ground vomiting
Melaena (black, tarry stools)
Fall in haemoglobin on a full blood count
Eating typically worsens the pain of gastric ulcers. The pain of duodenal ulcers tends to improve immediately after eating, followed by pain 2-3 hours later. Patients with gastric ulcers tend to lose weight due to the fear of pain on eating, whereas with duodenal ulcers, the weight is stable or increases. This helps you differentiate them in your MCQ exams.
