“Malignancy of the gastrointestinal tract”

  • Include:
    • Oesophageal cancer
    • Stomach cancer
    • Pancreatic cancer
    • Small bowel cancer
    • Biliary tract/gallbladder cancer
    • Liver cancer
    • Colorectal cancer
    • Anal cancer
Risk Factors
  • Oesophageal cancer:
    • GORD, alcohol, smoking, obesity, poor diet (lack of fruit and veg), achalasia, Paterson-Brown Kelly syndrome, tylosis
  • Stomach cancer:
    • Aged over 50, male, h. pylori, acid reflux, gastritis, pernicious anaemia, family history, smoking, obesity, occupational exposure to rubber or coal, high salt diet, alcohol, lack of fruit and vegetables, excess of processed meat
  • Pancreatic cancer:
    • Age 50-80, obesity, smoking/tobacco chewing, diabetes, chronic pancreatitis, stomach ulcer, h. pylori, family history, Lynch syndrome, Peutz Jeghers syndrome
  • Small bowel cancer – as for stomach (gastric) cancer
  • Biliary tract/gallbladder cancer:
    • Primary sclerosing cholangitis, bile duct abnormalities, biliary stones, liver fluke parasite, exposure to chemicals and toxins (thorotrast), hepatitis
  • Liver cancer:
    • Cirrhosis – alcohol misuse, hep B/C, haemochromatosis, primary biliary cirrhosis, obesity
  • Colorectal cancer:
    • Age over 60, high red meat/low fibre diet, overweight, inactivity, alcohol, smoking, family history, ulcerative colitis, Crohn’s disease
  • Anal cancer:
    • HPV, many sexual partners/anal sex (increased risk of HPV), history of cervical, vaginal or vulval cancer, smoking, immunocompromised (e.g. HIV)
Aetiology
  • Genetic predisposition
  • Environmental mutations
  • Oncoviruses
Pathophysiology
  1. Mutation inactivates tumour suppressor genes
  2. Cells proliferate
  3. Mutation inactivates DNA repair genes
  4. Mutation of proto-oncogenes creates an oncogene
  5. Mutation inactivates several more tumour suppressor genes
  6. Cells proliferate into a cancerous mass
Clinical Presentation
  • Oesophageal cancer:
    • Progressive dysphagia for solids then for liquids, weight loss, heartburn, reflux, anorexia, persistent, pain in epigastric region/chest/back, cough, hoarseness, fatigue, haemoptysis/haematemesis (both uncommon)
  • Stomach cancer:
    • Weight loss, nausea and vomiting, dysphagia, palpable mass, heartburn/reflux, anorexia, indigestion – burping, early satiety, epigastric pain, fatigue, anaemia
  • Pancreatic cancer:
    • Pain in back/stomach, worse lying down or after eating, weight loss, jaundice (yellow skin, dark yellow urine, pale stools), nausea and vomiting, changes in bowel movements, fever and night sweats, indigestion, blood clots
  • Small bowel cancer – as for stomach (gastric) cancer
  • Biliary tract/gallbladder cancer:
    • Jaundice, pruritis, pale stole, dark urine, fatigue and malaise, abdominal pain, ascites, fever, chills
  • Liver cancer:
    • Weight loss, anorexia, early satiety, abdominal pain, jaundice, pruritis, fatigue
  • Colorectal cancer:
    • Persistent blood in the stool, change in bowel habit, abdominal pain, weight loss
  • Anal cancer:
    • Rectal bleeding, itching and pain around the anus, palpable lumps around the anus, mucus discharge from the anus, bowel incontinence
Investigations
  • Oesophageal cancer:
    • Endoscopy and biopsy (lesion/mass found, cancer cells confirmed histologically), barium swallow/barium meal, CT scan, endoscopic USS, PET, laparoscopy
  • Stomach cancer:
    • Gastroscopy and biopsy, endoscopic USS, CT, PET, laparoscopy
  • Pancreatic cancer:
    • USS, CT, MRI, PET/PET-CT, EUS, endoscopic retrograde cholangiopancreatography (ERCP), laparoscopy, MRCP, biopsy
  • Small bowel cancer – as for stomach (gastric) cancer
  • Biliary tract/gallbladder cancer:
    • LFTs and tumour markers, USS, CT, MRI, ERCP, percutaneous transhepatic cholangiography (PCT), biopsy
  • Liver cancer:
    • USS, AFP blood tests, CT, MRI, biopsy, laparoscopy
  • Colorectal cancer:
    • Digital rectal examination, FBC, colonoscopy, CT colonography, CT scan, flexible sigmoidoscopy, MRI
  • Anal cancer:
    • Rectal examination, sigmoidoscopy, proctoscopy, biopsy
Management
  • Oesophageal cancer:
    • Stage 1-3 – surgery, then chemo/radiotherapy
    • Stage 4 – chemo/radiotherapy, stents, palliative care
  • Stomach cancer:
    • Surgery, chemotherapy, radiotherapy, targeted therapies, palliative care for advanced cancer
  • Pancreatic cancer:
    • Surgery – long recovery, chemotherapy, radiotherapy, clinical trial, palliative care
  • Small bowel cancer – as for stomach (gastric) cancer
  • Biliary tract/gallbladder cancer:
    • Surgery, stent, chemotherapy, radiotherapy, palliative care
  • Liver cancer:
    • Surgical resection, liver transplant, microwave/radiofrequency ablation, chemo for palliative care
  • Colorectal cancer:
    • Surgery, chemotherapy, radiotherapy, targeted therapies
  • Anal cancer:
    • Chemoradiation therapy, surgery, palliative care
Complications
  • Oesophageal cancer:
    • Tracheo-oesophageal fistulas, anaemia (from bleeding), weight loss, pneumonia, metastases – lymph nodes, liver, lungs, brain
  • Stomach cancer:
    • Pain, weight loss, dysphagia, nausea, vomiting, gastric bleed, metastases
  • Pancreatic cancer:
    • Jaundice, nausea, vomiting, digestive problems, pain, weight loss
  • Small bowel cancer – as for stomach (gastric) cancer
  • Biliary tract/gallbladder cancer:
    • Jaundice, pruritis, pale stole, dark urine, fatigue and malaise, abdominal pain, ascites, fever, chills
    • Surgery, stent, chemotherapy, radiotherapy, palliative care
  • Liver cancer:
    • Anaemia, bile duct obstruction – jaundice/itching/vomiting, portal hypertension – oesophageal varices (risk of rupture), hypercalcaemia, hepatorenal syndrome, hepatic encephalopathy
  • Colorectal cancer:
    • Intestinal obstruction, recurrence, metastases
  • Anal cancer:
    • Metastases

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