15 - GI Malignancy

Question 1

What are the most common GI malignancies in the UK in order?

Answer 1

- Bowel

• Pancreas
• Oesophagus
• Stomach
• Liver

(Bowel is 3rd most common cancer all over if you remove breast and testicular)

Question 2

What are some general symptoms for upper and lower GI malignancies?

Answer 2

Question 3

What is a common presentation of oesophageal cancer and what are some red flags along with this presentation?

Answer 3

Dysphagia: could be due to extraluminal, luminal or intra luminal reasons

Question 4

What are the red flags in this case?

Answer 4

• Dysphagia
• 3 months
• Tired (anaemia)
• Loss of weight

Question 5

What are the two main forms of oesophageal cancer and what is the prognosis for this type of cancer??

Answer 5

- Sqaumous cell carncinoma

- Adenocarcinoma (Barrett’s oesophagus)

Question 6

What are some differentials for epigastric pain?

Answer 6

Question 7

What are some red flags that can occur with epigastric pain that point towards a stomach malignancy?

Answer 7

• Malaena
• Haematemesis

Question 8

What is the most common type of stomach cancer?

Answer 8

• Adenocarcinoma from metaplasia or chronic gastritis
• Ulcers can be potentially malignant
• Occur mainly in the cardia or antrum

Question 9

What are the risk factors for stomach adenocarcinoma and what is the prognosis with this type of cancer?

Answer 9

• Smoking, high salt diet, family history, H.Pylori
• Anything that causes chronic inflammation
• Most stomach cancers present late so are advanced and poor prognosis

Question 10

Apart from adenocarcinomas, what other types of malignancy can occur in the stomach?

Answer 10

- Gastric lymphoma: MALT tissue, associated with H Pylori and has better prognosis. Most common primary site for gastrointestinal lymphoma

- Gastrointestinal stromal tumours: sarcomas and tend to find them accidentally on endoscopy

Question 11

What are some red flags with jaundice for liver malignancy?

Answer 11

• Hepatomegaly with irregular craggy border
• Unintentional weight loss
• Painless
• Ascites due to liver damage or compression so less proteins made

Question 12

What is the most common malignancy of the liver?

Answer 12

• Primary malignancy is rare but if it is, hepatocellular carcinoma from diseases like Hep B
• Gets a lot of metastases from BLTKP

Question 13

What are the risk factors for pancreatic cancer and what is the typical patient with this type of cancer?

Answer 13

• Over 60 usually with no specific cause
• Chronic pancreatitis, smoking and family history all increase risk
• Prognosis very poor, about 6 months

Question 14

What is the most common type of pancreatic cancer?

Answer 14

• Ductal adenocarcinoma
• Head of the pancreas

Question 15

What are some of the symptoms of pancreatic cancer?

Answer 15

• Painless jaundice as interferes with biliary flow
• Persistent pain that gets worse
• Weight loss
• Anorexia
• Fatigue
• Abnormal LFTs

Question 16

What is the most common type of small bowel cancer, what are the symptoms and risk factors?

Answer 16

• Adenocarcinoma
• VERY RARE even though it has a rapid cell turn over

Question 17

What symptoms can bowel obstruction cause and how can we diagnoses a bowel obstruction?

Answer 17

• Abdominal pain
• Abdominal distension
• Nausea/vomiting
• Complete constipation (no flatulence or stool)
• Do an abdominal x-ray and measure the diameters of each bowel

Question 18

What are some differentials for bowel obstruction?

Answer 18

Question 19

What are some red flags with bowel obsruction for malignancy?

Answer 19

• Unexplained abdominal pain in the umbilical regin before obstruction
• Unintentional weight loss

Question 20

What are some differential diagnoses for PR bleeding?

Answer 20

Question 21

What are some red flags with PR bleeding that could suggest a bowel malignancy?

Answer 21

Red flags are age dependent

Question 22

What can be some changes in bowel habit and what are some benign differentials for this?

Answer 22

• Change in frequency
• Change in consistency
• Associated symptoms like bloating or abdominal discomfort

Question 23

What are some red flags with changes in bowel habit?

Answer 23

Question 24

What is the most common type of large bowel cancer and what are the risk factors for this?

Answer 24

- Adenocarcinoma

• Usually adenomas from FAP undergo malignant changes. (Adenoma-Carcinoma sequence)

- Risks: family history, IBS, FAP, HNPCC, diet and lifestyle

Question 25

How do we screen for bowel cancer in the UK?

Answer 25

- Faecal occult to check for hidden blood then colonoscopy if so

Question 26

How can we view colorectal cancers and what is the most common site for them?

Answer 26

All colorectal cancers are adenocarcinomas - 50% rectal - 30% sigmoid Can view most of them using sigmoidoscope

Question 27

What are symptoms of rectal cancer and why?

Answer 27

- PR bleeding as ulcerating - Tenesmus due to distension of rectum

Question 28

What are the differences between right and left sided colon cancers?

Answer 28

**- Left:** stenosing. obstructive symptoms due to stenosis and harder contents **- Right:** presents later and more advanced as caecum and ascending colon are more distensible

Question 29

What is this sign and what is the diagnosis?

Answer 29

- Apple core sign - Stenosis showing large bowel obstruction and often malignant

Question 30

How do we stage colorectal cancers?

Answer 30

A - confined to mucosa B - musculature C - musculature and regional lymph node involvement D - metastases

Question 31

How do we manage a GI malignancy once we have a patient with red flags for it?

Answer 31

**Investigations:** TNM, blood tests for tumour markers and Hb, CT/MRI, endoscopy **Treatment:** chemo, radio, surgical resections

Question 32

What are tumour markers for pancreatic and bowel cancer?

Answer 32

**Bowel:** CEA **Pancreatic:** CA19-9

Question 33

Which part of the stomach is most prone to ulceration?

Answer 33

- Lesser curve - First part of duodenum

Question 34

What hormone is released in excess in Zollinger-Ellison syndrome?

Answer 34

Question 35

What blood test result when raised would most specifically indicate hepatocyte damage?

Answer 35

- ALT - ALP is biliary and bone disease - AST not specific to liver as released from skeletal and cardiac muscle too