1

Raquel Redmond
Sodexo Philadelphia Dietetic Internship

Medical Nutrition Therapy for Esophageal Cancer

2
Table of Contents
Abstract
.3
Introduction
4
Discussion of the
Disease.5
Anatomy of the Esophagus
Types of Esophageal Cancer
Risk Factors
Signs and Symptoms
Diagnosis
Labs
Esophageal Cancer Staging
Treatment
Medical Nutrition Therapy for Esophageal Cancer.15
Nutrition Assessment
Nutrition Diagnosis
Nutrition Intervention
Monitoring and Evaluation
Presentation of the Patient25
Critical Comments32
Summary.
35
References.3
6
Appendix.
41

3
Abstract
Esophageal cancer is a type of cancer that affects the structure which
connects the throat and the stomach known as the esophagus. Esophageal cancer
predominantly presents in the form of squamous cell cancer and adenocarcinoma
among rare other types. These types of cancer begin in the mucosal layer and
submucosal layer respectively. In many cases, gastroesophageal reflux disease
leads to Barretts esophagus which can progress to esophageal cancer. Obesity is
one of the major risk factors for esophageal cancer. Obesity is linked to esophageal
cancer through a decreased prevalence of Heliobacter pylori and adipocyte
secretion of mediators. Many of the risk factors, including tobacco use and alcohol
use, are modifiable and lifestyle changes can reduce the risk of this disease.
Esophageal cancer may first present itself with symptoms such as dysphagia,
chest pain, weight loss, hoarseness or chronic cough, and indigestion or heartburn.
To diagnose esophageal cancer, multiple tests may be done. Common methods to
confirm a diagnosis include an upper gastrointestinal series, computed tomography
(CT) scan, positron emission tomography (PET) scan, an endoscopy, and a biopsy.
Treatment of esophageal cancer is similar to other forms of cancer through
combinations of surgical intervention, chemotherapy, and radiation among other
targeted

treatments.

The

treatment

plan

for

esophageal

cancer

is

often

individualized and is determined based on the stage of the tumor. In general, stage
0, I, and IIA respond well to surgery. Stages IIB and III have poor survival rates with
only surgical resection. Nutritional implications of this disease vary from case to
case. Most commonly, patients are at risk for malnutrition due to dysphagia and

4
weight loss. Medical nutrition therapy is often key for managing these side effects.
In certain cases, enteral nutrition support is indicated and beneficial.

Introduction
Cancer is an ever changing and progressive disease characterized by an
uncontrolled growth of abnormal cells. The esophagus is the tube through which
food moves from the throat to the stomach. Esophageal cancer affects the digestive
tract and therefore can gravely affect the nutritional status of those affected by this
disease. When I first met JL, he had recently been diagnosed with adenocarcinoma
of the esophagus and had begun chemotherapy combined with radiation treatment.
He was also struggling to meet his nutritional needs evident through his drastic
unintentional weight loss and refusal to eat. During my time at the MD Cooper
Cancer Center, I was warmed by his support system each time I met with him. His
fianc and adorable little girls stood by him on even his darkest days. My interest in
cancer and my connection with JL led me to choose his case for this case study.
In 2014, it was predicted that there would be 18,170 new cases of
esophageal cancer and 15,450 estimated deaths within the year. 1 While esophageal
cancer may not be one of the most prevalent types of cancer, it is the 6 th leading
cause of death by cancer in males with an estimated 12,450 deaths in 2014. This
disease is three to four times more likely to affect men than women. 2 From 2004 to
2010, the survival rate for both men and women was 17.5%.. This rate has been
steadily increasing with the death rate falling about 0.7% each year. 1 I would like to
investigate further into the risk factors for this disease and learn more about the
course of treatment specific to this type of cancer. In addition, I would like to

5
identify the course of medical nutrition therapy that is most appropriate for
esophageal cancer cases.

Discussion of Disease
Anatomy of the Esophagus

6
The esophagus is a 25
cm long muscular tube that
extends from the pharynx to
the stomach. The esophagus
is divided into three sections
which include the cervical
portion, the thoracic portion,
and the abdominal portion.
Microscopically,
esophagus
layers

the

contains

which

include

four
the

mucosal layer, the submucosal layer,

Figure 1 Layers of the esophagus

the muscular layer, and the adventitial layer. The mucosal layer is mainly made up
of stratified squamous cells. The submucosal layer contains connective tissue and is
made up of gland cells that secrete mucus. The muscular layer is divided into
striated muscle cells located in the proximal one-third of the esophagus and mainly
smooth muscle in the distal portion. The adventitial layer is the final layer which
consists of fibrous connective tissue. 3 Esophageal cancer begins in the mucosa and
grows through the submucosal layer and eventually the muscular layer. 4
Types of Esophageal Cancer
There are multiple types of esophageal cancer. Squamous cell carcinoma
begins in the squamous cells that line the esophagus in the mucosal layer and it can
grow anywhere throughout the esophagus. Risk factors specific to this form of
esophageal cancer include heavy alcohol consumption and smoking tobacco.
Adenocarcinoma generally develops in the distal portion of the esophagus which

7
occurs when gland cells grow in the place of squamous cells. This form of
esophageal cancer is the most common. Risk factors specific to adenocarcinoma
include chronic acid reflux, Barretts esophagus, and obesity. Other rare types of
esophageal cancers can occur, such as lymphomas, melanomas, and sarcomas. 4,5
Risk Factors
There are several risk factors that increase the risk of developing esophageal
cancer. Some risk factors are more likely to increase the risk of one type of
esophageal cancer over another. Non-modifiable risk factors include age and
gender. Persons over the age of 55 are more likely to receive a diagnosis of
esophageal cancer and men are three times more likely than women. There are a
slew of modifiable risk factors that can increase the risk of developing esophageal
cancer. Modifiable risk factors include tobacco and alcohol use and obesity. 6
The use of tobacco can increase the risk of squamous cell type esophageal
cancer among other types of cancer. The annual number of esophageal cancer
deaths attributable to smoking for both men and women combined is around
12,000. Smoking cessation on the other hand can considerably decrease the risk of
esophageal cancer.2 Alcohol consumption is also carcinogenic due to being
metabolized into acetaldehyde and reactive oxygen species that damage DNA,
proteins, and lipids.

In addition, a deficiency in alcohol dehydrogenase, which

metabolizes alcohol, has been found to increase the risk of alcohol-related

squamous cell esophageal cancer. 7 When tobacco use is combined with heavy
alcohol consumption, it increases the risk of esophageal cancer even more. Both
tobacco use and alcohol consumption are also risk factors for adenocarcinoma. 6

8
One of the most significant risk factors for esophageal cancer is obesity.
Obesity increases the risk of gastroesophageal reflux disease (GERD) and Barretts
esophagus.8,9 Barretts esophagus is a complication of chronic acid reflux or GERD.
This is a condition in which the tissue lining the esophagus is replaced by
metaplastic columnar cells that are similar to those of the intestines. This can also
be referred to as dysplasia, or an abnormality of cells, that can lead to esophageal
cancer.10
There

are

multiple,

independent

factors

that

link

obesity

with

adenocarcinoma on top of chronic acid reflux. These factors include decreased

prevalence of Heliobacter pylori and adipocyte secretion of mediators. A reduction
in H. pylori increases gastric acidity and possibly increases appetite due to
increased ghrelin secretion. An increase in gastric acidity could contribute to the
progression of GERD to Barretts esophagus to adenocarcinoma. Increased leptin
levels and decreased adiponectin levels from adipocytes can lead to a change in the
esophageal epithelium. Elevated leptin has been associated with the progression of
adenocarcinoma. Decreased adiponectin levels have been associated with the
progression of Barretts esophagus to esophageal cancer. 8,9
Signs and Symptoms
The most common signs and symptoms of esophageal cancer are dysphagia,
chest pain, weight loss, hoarseness or chronic cough, and indigestion or heartburn. 11
Dysphagia is characterized a steady progression of difficulty swallowing solid foods
at first then liquids. This symptom occurs when the esophagus is constricted to less
than 14 mm wide. Chest pain may accompany dysphagia. Interestingly, excessive
mucus production can also be a symptom. The body produces mucus to help food

9
pass through the esophagus.12 Weight loss is common even if a good appetite is still
present due to patients unknowingly taking smaller bites and dysphagia that does
not allow them to have an adequate intake. A hoarse voice can be attributed to
compression of the laryngeal nerve. Complications include obstruction of the
esophagus, pain, and bleeding.11

Diagnosis
A diagnosis of esophageal cancer can be done through multiple tests
including an upper gastrointestinal series, computed tomography (CT) scan,
positron emission tomography (PET) scan, an endoscopy, and a biopsy. When
common signs and symptoms are present in combination with having some of the
risk factors associated with esophageal cancer, testing may be done to confirm a
diagnosis.13

10
An upper gastrointestinal series,
or barium swallow test, produces a
series

of

x-ray

images

of

the

esophagus, stomach and duodenum. In

order to collect these images, a patient
must first swallow a liquid that contains
barium. Barium coats the lining of the
esophagus and stomach so that it may
show up on x-ray images. This
test can show abnormal areas

Figure 2 A. esophageal cancer B. barium swallow

x-ray C. endoscopic view

where

the esophagus may have bumps or plateaus or areas causing a narrowing of the
esophagus. This test is meant to only show the lining of the esophagus and does not
determine how deep a cancer may go.13,14
An endoscopy is a test that uses a flexible, narrow tube with a camera,
otherwise known as an endoscope, to look inside the esophagus. A patient must be
sedated for this test to be performed. The endoscope goes down through the throat
and into the esophagus. Barretts esophagus can be diagnosed with an endoscopy
due to the altered appearance of the esophageal tissue. During an endoscopy, a
biopsy may also be performed. A biopsy is an examination of tissue to discover the
incidence, cause, or degree of a disease. Staging of esophageal cancer can be done
using the biopsy tissue sample.13
Multiple imaging tests can be done to conclude a diagnosis of esophageal
cancer. A computed tomography (CT) scan takes a series of x-rays taken at different
angles and combines them to make cross-sectional images of the bones and soft
tissue. CT scans are mainly used to determine the location of esophageal cancer

11
and to see if it has spread. In
order to perform a CT scan,
oral contrast must be used to
help outline the esophagus. A
biopsy may be done during a

Figure 3 CT scan on left, PET scan on right

CT scan which helps to guide the needle. A positron emission tomography (PET)
scan uses fluorodeoxyglucose (FDG), a radioactive substance, to show the presence
of cancer cells. Cancer cells absorb large amounts of FDG so they are more visible
with a PET scan. In some instances PET scans and CT scans are done together. 13
Magnetic resonance imaging (MRI) is being assessed for use as a reliable tool
in the diagnosis of esophageal cancer. A recent study from the Public Library of
Science has found that MRI is a more reliable diagnostic method than an endoscopy
with in the Levrat model. This model is shown to effectively replicate the
progression of disease from GERD to Barretts esophagus to adenocarcinoma. By
using this method the authors were able to determine that MRI was able to correctly
identify cancer 85.3% of the time. Unlike an endoscopy, an MRI has the potential to
quantify the size and number of tumors more reliably while being non-invasive. 15
Labs
A complete blood count evaluates white blood cells, red blood cells, and
platelets. White blood cell evaluation is made up of total white blood cell count and
levels of neutrophils, lymphocytes, monocytes, eosinophils, and basophils. A low
white blood cell and neutrophil count may indicate cancer that has metastasized to
the bone marrow. A low neutrophil count also indicates bone marrow damage due to
chemo radiation therapy which can also be shown through low lymphocyte count.

12
Red blood cell evaluation is made up of total red blood cell count, hemoglobin,
hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, red cell
distribution width, and reticulocyte count. A low red blood cell count, along with a
low hemoglobin and hematocrit, is known as anemia and could be due to bleeding
which is one of the complications of esophageal cancer. Platelet evaluation is made
up of total platelet count, mean platelet volume, and platelet distribution width. A
high platelet count can be seen in cancer and is known as thrombocytosis, but a low
count could also be seen during chemo radiation therapy which is known as
thrombocytopenia.16
Tumor marker tests measure the presence, levels, or activity of specific
proteins or genes in tissue, blood, or other bodily fluids that may be signs of cancer.
This test is important to determine if a tumor will respond to targeted therapy and
to monitor for recurrence of the cancer. In the case of esophageal cancer, tumor
marker tests would be specifically looking for the HER2 or VEGF proteins. I will
discuss targeted therapy in more detail in a later section. 17
Esophageal Cancer Staging

13
Staging
esophageal

of
cancer

depends

on

multiple

factors.

TMN

staging

refers to how deep a

tumor has gone into
the

lining

esophagus,

of

the
the

location of the tumor,

Figure 4 Esophageal cancer staging

and whether or not the cancer has metastasized. Tumors are also given a
histological grade which refers to how normal cells look under a microscope. Higher
grade tumors have a tendency to grow and spread faster than lower grade tumors.
There are multiple staging categories that must be discussed in order to understand
stage grouping. Please see the table below describing TNM staging and histological
grade:18,19
Table 1 TNM Staging
Primary tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
High-grade dysplasia
T1
Tumor invades lamina propria, muscularis mucosae, or submucosa
T1a
Tumor invades lamina propria or muscularis mucosae
T1b
Tumor invades submucosa
T2
Tumor invades muscularis propria
T3
Tumor invades adventitia
T4
Tumor invades adjacent structures
T4a
Resectable tumor invading pleura, pericardium, or diaphragm
T4b
Unresectable tumor invading other adjacent structures, such as the
aorta, vertebral body, and trachea
Regional lymph nodes (N)
NX
Regional lymph node(s) cannot be assessed
N0
No regional lymph node metastasis
N1
Metastasis in 1-2 regional lymph nodes

14
N2
Metastasis in 3-6 regional lymph nodes
N3
Metastasis in 7 or more regional lymph nodes
Distant metastasis (M)
M0
No distant metastasis
M1
Distant metastasis
Histologic grade (G)
GX
Grade cannot be assessed stage grouping as G1
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiated
G4
Undifferentiated stage grouping as G3 squamous
Table 2 Histological Grade
Stage
0
IA
IB

T
Tis (HGD)
T1
T1
T2-3
T2-3
T2-3
T2-3
T1-2
T1-2
T3
T4a
T3
T4a
T4b
Any
Any

IIA
IIB
IIIA
IIIB
IIIC
IV

N
N0
N0
N0
N0
N0
N0
N0
N1
N2
N1
N0
N2
N1-2
Any
N3
Any

M
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M1

Grade
1, X
1, X
2-3
1, X
1, X
2-3
2-3
Any
Any
Any
Any
Any
Any
Any
Any
Any

Tumor location
Any
Any
Any
Lower, X
Upper, middle
Lower, X
Upper, middle
Any
Any
Any
Any
Any
Any
Any
Any
Any

Treatment
There are multiple treatment paths for esophageal cancer. Surgical resection
of the esophagus is most commonly combined with chemotherapy and radiation. In
general, stage 0, I, and IIA respond well to surgery. Stages IIB and III have poor
survival

rates

with

only

surgical

resection.

The

operation

is

called

an

esophagectomy in which a portion of the esophagus and possibly the surrounding

lymph nodes are removed and the stomach is stretched up to join the remaining
part of the esophagus. If the cancer is in the distal portion of the esophagus, part of

15
the stomach will be removed as well. Preoperative chemotherapy and radiation, in
addition to surgery, produces the best outcomes. Surgery for stage IV esophageal
cancer

is

not

recommended.

Complications

of

surgical

resection

include

anastomotic leaks, fistulas, strictures, bilious gastroesophageal reflux, and dumping

syndrome.12,20
Chemotherapy and radiation are generally done in conjunction with one
another. There are two types of radiation known as external-beam radiation and

internal radiation or brachytherapy.

For
esophageal cancer, external-beam radiation
Figure
5 Esophagectomy
therapy is most often used. Radiation to the esophagus may worsen dysphagia in
the beginning. Side effects of treatment to the esophagus include sore throat,
cough, shortness of breath, red or itchy skin, and painful swallowing. Palliative
radiation may be appropriate to treat symptoms of the disease if the cancer cannot
be cured. The most common chemotherapy for esophageal cancer is cisplatin and
5-fluorouracil when combined with radiation. Possible side effects of chemotherapy
include nausea and vomiting, loss of appetite, hair loss, mouth sores, diarrhea or
constipation, and fatigue.20
In most cases, patients have already lost weight when beginning treatment
for esophageal cancer. Supportive care by way of enteral nutrition support can be
helpful. The nutrition support access is placed before or during treatment to attempt

16
to improve nutritional status and help patients maintain their weight throughout
treatment.12 Weight loss is a characteristic of malnutrition which is reported in 6085% of patients with esophageal cancer. Nutrition support combined with treatment
can improve tolerance of treatments, a patients quality of life, and long term
outcomes.21
There are two forms of targeted drugs that may be used to treat esophageal
cancer. Trastuzumab, a humanized IgG1 antibody that targets HER2, is used in
conjunction with chemotherapy once every three weeks. This drug is designed to
target HER2 protein cells present on the surface of esophageal cancer cells which
are overexpressed in gastrointestional tumors. 22,23 Side effects of this drug include
fever, chills, weakness, nausea, vomiting, cough, diarrhea, and headaches. 22
Another targeted drug is called Ramucirumab that is given every two weeks. This
drug targets VEGF, a protein that binds to receptors to tell the body to make new
blood vessels and stimulates tumor cell growth. Ramucirumab binds to these
receptors instead of VEGF and can slow or stop the growth of cancer cells. 22,23 VEGF
is overexpressed in 30-60% of esophageal cancer patients. 23 Common side effects
include high blood pressure, headaches, and diarrhea. Targeted therapy is mainly
used when chemotherapy does not work or in conjunction with chemotherapy. 22
In addition to these traditional cancer treatments, endoscopic treatments
may be used for early stages of esophageal cancer or to help relieve symptoms of
late stage esophageal cancers. Endoscopic mucosal resection is used to remove
abnormal tissue and proton pump inhibitors are taken to suppress acid production in
the stomach to keep dysplasia from recurring. Photodynamic therapy (PDT) is used
to improve swallowing in cases of early stage large cancers. PDT destroys cancer
cells and usually does not affect healthy cells. Radiofrequency ablation is used to

17
treat dysplasia of Barretts esophagus. It kills the abnormal cells and then allows
normal cells to grow and replace Barretts cells. Lastly, an esophageal stent can be
placed in the esophagus and helps to relieve trouble swallowing in most patients
with tumors that are blocking the esophagus. 24

Figure 6 Esophageal stent

Medical Nutrition Therapy for Esophageal Cancer

Medical

nutrition

therapy

in

oncology

is

extensive

and

somewhat

complicated. There are many nutritional side effects to treatment through

chemotherapy, radiation therapy, and surgery. The role of a Registered Dietitian for
patients with esophageal cancer is to identify and correct nutritional impact
symptoms, emphasize adequate protein and energy intake, and to consider
supplementation for additional support. If indicated, the registered dietitian should
also provide support and monitor the use of enteral or parenteral nutrition. 25 The
Evidence Analysis Library concludes, with limited good supporting evidence, that
intervention by a registered dietitian is associated with improved outcomes in

18
esophageal cancer patients. These improved outcomes include decreased weight
loss, fewer unplanned hospital admissions, shorter length of stays during hospital
admissions, improved tolerance of treatments, and higher percent desired radiation
received.26 A recent journal article in Diseases of the Esophagus states that
dietitian-delivered intensive nutritional support preserves preoperative weight and
decreases postoperative complications in patients who have undergone an
esophagectomy.27
Nutrition Assessment
The

nutrition

assessment

for

patients with esophageal cancer should

follow the general oncology assessment
including

the

five

domains

of

the

nutrition care process. These domains

are

food/nutrition-related

history,

anthropometric measures, biochemical

data, medical tests, and procedures,
nutrition-focused physical findings, and
client/social history. The six

Figure 7 Nutrition Care Process

indicators of malnutrition, energy intake, interpretation of weight loss, body fat,

muscle mass, fluid accumulation, and reduced grip strength, should also be
considered during the assessment.28
Food/nutrition-related history
There are many areas that should be covered when obtaining a patients
food/nutrition-related history. Current food and beverage intake should be assessed

19
for adequacy of energy, protein, nutrients, and fluid. Use of dietary supplements
should be discussed. Assessing the patients knowledge level and motivation based
on their prognosis is important. Lastly, evaluating presence of nutritional impact
symptoms, such as anorexia, nausea, vomiting, dysphagia, fatigue, use of
complementary and alternative medicine therapies, etc. should be discussed. 28
Anthropometric measures
Height, weight, body mass index, weight history, body composition, and
weight distribution are all included in anthropometric measures. Body weight should
be taken initially before treatment begins and routinely throughout treatment. This
is important because cancer patients who experience weight loss of 10% or more
have shorter survival than those without weight loss. Patients at risk are those who
have lost 5% body weight over one month or 10% body weight over six months.
Weight history in general is very important and a baseline weight should be
established for comparison throughout treatment. 28 A study discussing weight loss
and resting energy expenditure concluded that impaired nutritional status, elevated
energy expenditure, and higher inflammation status are more common in patients
with newly diagnosed esophageal cancer who have lost weight. 29
Biochemical data and medical tests
The results of various lab and medical tests should be included in the
nutrition assessment. A complete blood count evaluates white blood cells, red blood
cells, and platelets, and tumor marker tests may also be done. Medical tests include
an upper gastrointestinal series, computed tomography (CT) scan, positron emission
tomography (PET) scan, an endoscopy, and a biopsy. 28
Nutrition-focused physical findings

20
Nutrition-focused physical findings can help determine the presence of
nutritional deficiencies. In oncology, these nutritional deficiencies can present as
cancer cachexia or poor wound healing. Patients with esophageal cancer may
present with signs of aspiration, dehydration, and muscle wasting. 25 Possible
nutritional impact symptoms to be aware of include nausea, vomiting, dysphagia,
odynophagia, diarrhea, and weight loss.28
Client/social history
Client/social history combines past and present information to obtain a wellrounded view of the patient. Information that should be obtained for this portion of
the assessment includes current clinical status or prognosis, past medical history,
medication use, physical activity level, socioeconomic status, and social support. It
can also be important to note if the patient uses complementary and alternative
medicine

therapies

due

to

the

possibility

that

some

therapies

may

be

contraindicated in traditional therapies and recovery. 28

Estimated nutrition needs
Determining nutrition needs of a patient with esophageal cancer is important
for weight maintenance. Depending on the patients energy needs 25-40 kcal/kg of
body weight will be appropriate. If the patient is in a hypermetabolic state the
nutrient needs will be on the higher end between 30-35 kcal/kg. Patients that are in
a normal metabolic state or are sedentary can maintain body weight using 25-30
kcal/kg. Obese cancer patients may only need 21-25 kcal/kg/day. In patients
undergoing treatment, 1.2-1.5 g/kg of body weight will be appropriate protein
needs. A non-stressed oncology patient may only need 1-1.2 g/kg of body weight to

21
meet their protein needs. Once the needs are determined they should be
reevaluated and adjusted routinely throughout the course of treatment. 28
In order to achieve estimated nutrition needs oral nutrition support can be
offered. There are a variety of oral supplements available to help patients reach
their goals. Examples of oral nutrition supplements include Ensure products, Boost
products, and Glucerna for diabetic patients among others. When oral nutrition
supplements are not enough, enteral or parenteral nutrition support may be
indicated.
Nutrition Diagnosis
The nutrition diagnosis is meant to identify specific nutrition problems that
can be resolved or improved through nutrition intervention by a registered
dietitian.30 Common diagnoses in oncology include inadequate oral intake (NI-2.1),
unintended weight loss (NC-3.2), underweight (NC-3.1), malnutrition (NI-5.2),
unintended weight gain (NC-3.4), food and nutrition knowledge deficit (NB-1.1), and
undesirable food choices (NB-1.7). 28 The diagnosis should be written using the
problem, etiology, and signs and symptoms format. All three domains (intake,
clinical, and behavioral-environmental) can be used in an oncology setting. 30
Nutrition Intervention
The purpose of the nutrition intervention is to outline specific actions that will
be used to manage the nutrition diagnosis. During cancer treatment interventions
should revolve around weight maintenance and managing treatment-related side
effects. Interventions must be individualized according to the patient based on their
diagnosis,

prognosis,

and

symptoms.

These

interventions

include

dietary

modifications, oral nutrition supplementation, and enteral or parenteral nutrition. 30

22
Esophageal cancer treatments have various associated symptoms. The
symptoms are listed below according to treatment. In order to manage and improve
these symptoms there are a variety of nutrition interventions that can be done.
Chemotherapy
symptoms:
Anorexia
Nausea
Vomiting

Fatigue

Weight loss

Radiation symptoms:

Xerostomia
Mucositis
Sore mouth

Postoperative symptoms:

and

Gastroparesis
Indigestion
Acid reflux

throat
Dysphagia
Odynophagia
Alterations in taste

Dysphagia
Decreased motility
Anastomotic leak

and smell
Fatigue
Loss of appetite

Weight loss is common in patients undergoing treatment for esophageal

cancer and other cancers as well. Strategies to prevent weight loss include eating
small, frequent, nutrient dense meals, adding additional protein and calories to
foods, using oral nutrition supplements, and being well stocked with nutrient dense
foods. Anorexia may be causing weight loss and this symptom can be combated
with eating meals and snacks in a positive atmosphere, taking advantage of times
when appetite is present, and maintaining a physical activity regimen. Another
symptom that could contribute to weight loss is nausea and vomiting. Coping with
nausea and vomiting can be done by drinking room temperature liquids in small
amounts, avoiding high fat or overly sweet foods, avoiding foods with strong odors,
and eating bland, easy to digest foods. 30
Fatigue

23
Fatigue is another common symptom among many types of cancer. Fatigue
can be combated with having easy to prepare foods at home, always having
nutrient dense snacks available, drinking plenty of fluids, and being as physically
active as possible.30
Sore mouth and throat and xerostomia
A sore mouth and throat can be attributed to radiation therapy and is not
always a symptom. Strategies to meet nutrition needs with a sore mouth and throat
include eating soft, moist foods, avoiding alcohol, citrus, caffeine, tomatoes,
vinegar, and hot peppers, maintaining good oral hygiene, and eating foods at room
temperature. Xerostomia, or dry mouth, also can be managed by maintaining good
oral hygiene sipping on liquids throughout the day, using tart foods to stimulate
saliva, and eating soft, moist food with extra sauces. 30
Altered taste or smell
An altered taste or smell can be managed with good oral hygiene, using
spices to mask unpleasant tastes, and using plastic utensils if metallic tastes
become an issue. Some foods, such as meat, may become unappealing during
treatment. Other protein options are dairy products, eggs, legumes, fish, poultry,
and nut butters.30
Postoperative intervention
For patients who have undergone surgery to treat esophageal cancer, a soft,
low-fat diet with small, frequent meals is recommended. Recommended foods
include all dairy products, tender cooked meats, eggs, dried beans and peas,
smooth peanut butter, hot cereals, cold cereals with milk, pasta, rice, cooked grains,

24
cooked fruits, soft fresh fruit, fruit juice, cooked soft vegetables, vegetable juice,
and all beverages except alcohol, carbonated beverages, hot drinks, and juice with
pulp. Foods that are not recommended include tough or fatty meats, fried meats,
nuts, high fiber cereals, crusty bread, crackers, crunchy raw fruit, dried fruits,
crunchy vegetables, crunchy foods, foods with hard edges, and popcorn. 31
Enteral and parenteral nutrition

25
Many

times

gastrostomy

tube

or

jejunostomy

tube

is

placed proactively before

chemotherapy

and

radiation therapy have

begun. This is a way to
ensure that patients will
be able to meet their
nutrition needs in case
they begin to experience
side

effects

such

as
Figure 8 Examples of enteral access

dysphagia or nausea and

vomiting due to their course of treatment. Indications for enteral nutrition are as
follows,

inadequate

oral

intake

causing

anorexia

or

nausea,

esophageal

obstructions, dysphagia, and perioperative malnutrition. 28 According to the evidence

analysis library, enteral nutrition for severely dysphagic esophageal cancer patients
providing 37 kcal/kg/day and 2 g protein/kg/day resulted in weight maintenance and
stable albumin levels. This was determined with limited supporting evidence. 26 A
more recent study suggests that nutrition support in combination with surgical and
pharmacologic therapy improves patient outcomes, tolerance of treatment, and
quality of life.32
However a study has found that routine placement of enteral access is not
necessary in esophageal cancer patients. While this study was retrospective they
found that there were not differences in the nutritional assessments of those who

26
received enteral nutrition and those who did not. There were similar amounts of
postoperative complication rates and similar decreased nutritional parameters in
those who underwent chemoradiotherapy. This study suggests that enteral nutrition
should not be a routine intervention, but that it is essential part of therapy when
indicated.33
A comprehensive nutrition assessment should be done before deciding which
route should be used for enteral nutrition. The options include a nasogastric or
nasoenteric tube for short term use and a gastrostomy tube or jejunostomy tube for
long term use over four weeks. In general, a nasogastric or nasoenteric tube is not
indicated in esophageal cancer patients because of possible problems with pain and
swallowing. A jejunostomy tube is indicated for esophageal cancer patients because
of possible esophageal surgery gastroparesis. 28 In addition, according to a study
looking at implementing early versus late enteral nutrition after an esophagectomy
there is no significant difference in postoperative complications when beginning
enteral nutrition within or after 3 days. 34 The limitation to using a jejunostomy tube
is that calorically dense formulas and high rates are generally not appropriate. 28
When choosing an enteral formula for the patient, there are several factors
that must be considered. These factors include the location of access, digestive
abilities of the gastrointestinal tract, comorbid conditions that may indicate a
disease-specific formula, estimated nutrition needs, and long-term nutrition goals. 35
There are disease-specific formulas that are supplemented with eicosapentaenoic
acid and docosahexaenoic acid. This type of formula can be appropriate for
oncology patients. The 2 g daily recommended serving of eicosapentaenoic acid
and docosahexaenoic acid has been shown to limit tumor-induced weight loss by
interfering with signaling pathways of pro-inflammatory cytokines and proteolysis-

27
inducing factor.28 These formulas are associated with maintenance of weight and
lean body mass in patients undergoing an esophagectomy. 36 Another study suggests
that this type of formula is also beneficial to esophageal cancer patients undergoing
chemoradiotherapy.37
While
nutrition

enteral
is

always

preferred over parenteral

nutrition

due

reduction

in

rates

to

infection

associated

enteral

nutrition

sometimes

is

indicated

in

patients.
for

nutrition
moderate

with
it

oncology
Indications

the

parental
include

to

malnourished

severely
patients

administered 7 to 14 days
preoperatively,
malnourished

patients

who anticipate being unable

Figure 9 Long term vascular access for parenteral nutrition

to absorb nutrients for an extended period of time, and when the gastrointestinal
tract cannot be used. Parental nutrition should not be used routinely in cancer
patients undergoing major surgery and not routinely in conjunction with patients
undergoing chemotherapy.26

28
According to the Evidence Analysis Library, patients receiving parenteral
nutrition had significant decreases in weight. Also, there was no significant
difference between patients who received parenteral nutrition and those who did
not referring to chemoradiotherapy toxicity, postoperative complications, length of
hospital stay, length of stay in the intensive care unit, treatment response, and
mortality. However, patients receiving parenteral nutrition were more likely to
receive scheduled chemoradiotherapy treatments although it did not improve
effectiveness of the treatment. Again, these conclusions were drawn with limited
supporting evidence.38
Parenteral and enteral nutrition can both be used postoperatively after an
esophagectomy. One study compared the effect of nutrition support on immune
function after esophageal cancer surgery. The findings suggest that there is no
difference in immune function, nutritional state, or inflammatory response between
patients that received parenteral versus enteral nutrition. This also suggests that
either parenteral or enteral nutrition can be safely used after surgery. 39
Monitoring and Evaluation
The goal of monitoring and evaluation in the nutrition care process is to
determine the effect that the registered dietitian is having in the given scenario. By
using indicators, a registered dietitian can measure the success of the interventions.
These indicators should match signs and symptoms. 30 Specifically in the case of
esophageal cancer, the registered dietitian should be aware of symptoms such as
anorexia,

nausea,

vomiting,

fatigue,

dysphagia,

sore

mouth

and

throat,

odynophagia, xerostomia, mucositits, and alterations in taste and smell. 28 The goal

29
of care is to meet the nutritional needs of the patient. If objectives and goals are
written in measureable terms, then evaluating progress is much simpler.
In conclusion, the role of a registered dietitian in esophageal cancer is to
identify and correct nutritional impact symptoms, emphasize adequate protein and
energy intake, and to consider supplementation for additional support or monitor
enteral or parenteral nutrition if indicated. There are multiple interventions that may
be successful in achieving estimated nutrition needs of an esophageal cancer
patient including dietary modifications, oral nutrition supplementation, enteral and
parenteral nutrition.
Presentation of the Patient
JL is a 37 year old Caucasian male with esophageal cancer who was
diagnosed in August 2014. When JL initially realized something was wrong, his
symptoms included difficulty swallowing and pain while swallowing. In general he
was only eating soft foods, but in order to eat solid foods he was cutting it into small
pieces and requiring water to help food pass through the distal esophagus. JL was
also reporting a very poor appetite and dry heaves. His past medical history
includes gastroesophageal reflux disease, about 20 years of heavy drinking, and 25
years of smoking one pack of cigarettes per day. In addition, JL was classified as
morbidly obese with a BMI of 37.6 in January of 2014 before he began to lose weight
due to his symptoms.
JL began having difficulty swallowing in January of 2014 and went to the
emergency room at Cooper University Hospital with dysphagia in May. In July, he
had an esophagogastroduodenoscopy done which revealed an esophageal
stricture/mass extending down to the gastroesophageal junction. JL then had a

30
biopsy done which revealed poorly differentiated adenocarcinoma. A positron
emission tomography scan showed intense uptake in the lower third of the
esophagus extending to the gastroesophageal junction with no definite regional or
distant metastases. An endoscopic ultra sound performed in July showed the mass
extending into the muscularis propria. The tumor was deemed a T2 versus T3 N0M0,
33-40 cm large, and HER2 negative. Chemotherapy and radiation were discussed
with JL. In late August, he got a port placed for chemotherapy and a jejunostomy
tube placed due to significant weight loss since January 2014. This was his only
hospital stay after being diagnosed with esophageal cancer. In mid-September, JL
began his five week course of carboplatin and taxol in conjunction with radiation
treatment.
Over the course of eleven months, JL unintentionally lost a total of 89 pounds
from January 2014 to December 2014. Although JL had a jejunostomy tube placed
he was having extreme difficulties with nausea, vomiting, bloating, and overall
discomfort. He was very stubborn by not following his tube feed regimen even when
trying multiple formulas as an attempt to resolve his symptoms. His fianc was
taking care of him at home and was managing his jejunostomy tube.
Table 3 Weight History
Date
January 2014
July 28, 2014
August 14, 2014
August 28, 2014
September 18, 2014
October 3, 2014
October 17, 2014
November 20, 2014
December 1, 2014

Weight
277 lbs
247 lbs
245 lbs
233 lbs
225 lbs
216 lbs
208 lbs
199 lbs
188 lbs

Weight change
0
-30 lbs
-2 lbs
-12 lbs
-8 lbs
-9 lbs
-8 lbs
-9 lbs
-11 lbs

31
JL first got his jejunostomy tube placed on August 29, 2014. His regimen in
the hospital was Vital 1.5 at 80 milliliters per hour for 24 hours. JL was then only
seen as an outpatient at the MD Anderson Cancer Center when he was there for
scheduled chemotherapy and radiation treatments. During his initial nutrition
assessment on September 18, 2014, the dietitian recommended his home tube feed
regimen to be Isosource 1.5 at 110 milliliters per hour for 16 hours. This provides
2,625 calories, 118 grams of protein, and 1,358 milliliters of free water.
Unfortunately, JL did not want to have tube feeds and when he did use them he was
only using 2 cans of Isosource 1.5 at 65 milliliters per hour which eventually he
increased to 110 milliliters per hour. After discussing his symptoms which included
nausea, vomiting, diarrhea, and abdominal pain, we gave him other tube feeds to
try at home. We provided him with Boost High protein to trial at 80 milliliters per
hour, Jevity 1.0 and Vital 1.5. At this point we were hoping to provide him with any
nutrition possible. Per a diet recall JL was only consuming some soups and 48 oz of
water per day.
JLs diagnosis is inadequate energy intake (NI-1.4) related to esophageal
cancer and treatment as evidenced by unintentional weight loss of >5% in one
month or >10% in six months. Our interventions include discussion of soft foods,
high protein and high calorie foods, encouraging intake by mouth and also
encouraging use of the jejunostomy tube. For monitoring and evaluation, we used
daily or weekly weights, discussed symptoms and changed tube feeding products
accordingly, checked labs and medications (which can be found in the appendix),
and provided support throughout his treatment. Most recently, JL cancelled his
appointment with the surgeon for his esophagectomy and I am unsure whether he
followed through with another appointment or not.

32

October 17, 2014

Initial Dietetic Intern Nutrition Assessment
A) Patient presents to outpatient cancer center for scheduled chemotherapy and
radiation appointments. PMH includes esophageal reflux, esophageal cancer.
WEIGHT: 208#
DIET HX: mechanical soft diet and thin liquids

33
PO INTAKE: poor; tries to drink plenty of water and eats soups, cabbage, drinks 3
Ensures per day
GI: weight loss, dysphagia, anorexia, and heartburn, + J-tube
LABS: Na 142 WNL, K 4.5 WNL, Cl 103 WNL, CO2 26 WNL, BUN 9 WNL, Creat 0.74
WNL, BG 85 WNL, Ca 9.5 WNL, Alb 4.4 WNL, WBC 3.5 WNL, RBC 4.06 L, Hbg 12.3
L, Hct 36.6 L, Plt 189 WNL (10/16/2014)
MEDS: Oxycodone, Zofran, Carafate, Compazine, Roxicodone, Esomeprazole
SKIN: no documented wounds
Patient complains of decreased appetite, nausea and bloating with tube feeds.
Discussed ways to increase hydration, encourage d use of J-tube, and discussed
protein rich foods that he can tolerate.
D) Inadequate energy intake (NI-1.4) related to esophageal cancer and treatment
as evidenced by unintentional weight loss of >5% in one month or >10% in six
months.
I) Isosource 1.5 at 110 milliliters per hour for 16 hours. This provides 2,625 calories,
118 grams of protein, and 1,358 milliliters of free water.
M/E) GOAL: Weight maintenance and tube feed regimen to provide 80-100% of
estimated nutrient needs. Will monitor weight, PO intake, GI symptoms, labs, and
meds. Follow-up in 3-5 days.
October 21, 2014
Follow-Up Nutrition Assessment

34
A) WEIGHT: 208#
DIET HX: mechanical soft diet and thin liquids
PO INTAKE: poor; drinking three 16 oz bottle of water per day and continues with
soups and Ensures
GI: weight loss, dysphagia, anorexia, and heartburn; + J-tube; +
nausea/vomiting, is not tolerating the tube feeds well feels bloated and feels
like crap
Patient is currently using Isosource 1.5 at 110 milliliters per hour, but he is not
tolerating well. Gave him Boost high protein to trial through his J-tube at 80
milliliters per hour to see if it is better tolerated as a 1.0 kcal formula with no
fiber. Patient also left with Jevity 1.0 and Vital 1.5 to trial at home.
D) Inadequate energy intake (NI-1.4) related to esophageal cancer and treatment
as evidenced by unintentional weight loss of >5% in one month or >10% in six
months.
I) Isosource 1.5 at 110 milliliters per hour for 16 hours. This provides 2,625 calories,
118 grams of protein, and 1,358 milliliters of free water.
t/c Reglan if no improvement in symptoms.
Encourage PO intake.
M/E) GOAL: Weight maintenance and tube feed regimen to provide 80-100% of
estimated nutrient needs. Will monitor weight, PO intake, GI symptoms, labs, and
meds. Follow-up in 3-5 days.

35

October 24, 2014

Follow-Up Nutrition Assessment
A) WEIGHT: 207#
DIET HX: mechanical soft diet and thin liquids
PO INTAKE: poor; now drinking 5 pint bottles of water per day and continues with
soups, sometimes is able to tolerate Ensure Shakes
GI: weight loss, dysphagia, anorexia, and heartburn; nausea slightly improved;
excessive saliva production noted
Patient refused to try other tube feeds at home over the weekend. Fluid intake is
not optimal. Patient is making an effort to eat and drink more. Gave patient
samples of Ensure Active to try as he seems to tolerate juices well and he has no
interest in continuing with milky consistency drinks.
D) Inadequate energy intake (NI-1.4) related to esophageal cancer and treatment
as evidenced by unintentional weight loss of >5% in one month or >10% in six
months.
I) Isosource 1.5 at 110 milliliters per hour for 16 hours. This provides 2,625 calories,
118 grams of protein, and 1,358 milliliters of free water.
Ensure Active for additional kcal.
Encourage PO intake.

36
M/E) GOAL: Weight maintenance and tube feed regimen to provide 80-100% of
estimated nutrient needs. Will monitor weight, PO intake, GI symptoms, labs, and
meds. Follow-up in 3-5 days.

December 9, 2014
Follow-Up Nutrition Assessment
A) WEIGHT: 188#
DIET HX: mechanical soft diet and thin liquids
PO INTAKE: improved; patient reports higher water intake, eating soups, soft
foods, and sometimes drinks Ensure Active
GI: weight loss, dysphagia, anorexia, and heartburn; nausea is better controlled
Patient reports everyday he is eating more and throwing up less. Patient is no
longer interested in chemotherapy and radiation treatment. States he feels a
little better every day, but still having trouble tolerating tube feeds focuses his
efforts mostly on eating by mouth. Patient continuing to lose weight. Total weight
loss to date 89#.
D) Inadequate energy intake (NI-1.4) related to esophageal cancer and treatment
as evidenced by unintentional weight loss of >5% in one month or >10% in six
months.
I) Isosource 1.5 at 110 milliliters per hour for 16 hours. This provides 2,625 calories,
118 grams of protein, and 1,358 milliliters of free water.

37
Encourage PO intake.
M/E) GOAL: Weight maintenance and tube feed regimen to provide 80-100% of
estimated nutrient needs. Will monitor weight, PO intake, GI symptoms, labs, and
meds. Follow-up in 3-5 days.

Critical Comments
The nutritional course of JLs care was the best that we could give him while
following the nutritional guidelines as per the Nutrition Care Manual. During his
chemotherapy and radiation treatments I saw him a number of times in just a
couple of weeks. When I was not there he was seen by the Registered Dietitian each
week as well. Our goals were to meet JLs estimated nutritional needs, weight
maintenance, and manage symptoms affecting his nutrition. Unfortunately, our
goals were not met, but we did our best. I do not believe that there is anything we
could have done differently in order to prevent his weight loss or meet more of his
needs. We encouraged him to take as much by mouth as possible and to use his
jejunostomy tube to meet the rest of his needs. His fianc also encouraged him at
home.
For his tube feeds at home we recommended Isosource 1.5 at 110 milliliters
per hour for 16 hours. This provided JL with 2,625 calories, 118 grams of protein,
and 1,358 milliliters of free water. This alone would have met his needs since we
were aware that his by mouth intake had greatly declined. When he was able to

38
take some foods by mouth, we suggested a variety of soft foods and oral nutrition
supplements to help him reach his estimated nutrient goals. The physicians were
proactive in placing the jejunostomy tube because a decrease in appetite and ability
to eat is common amongst esophageal cancer patients. As part of the team, the
physicians expected us to provide JL with recommendations to increase his intake
and develop an appropriate tube feeding regimen.
One thing that we could have looked into in more detail was getting to the
bottom of JLs difficulty with his tube feedings. He expressed his concerns about
feeling bloated, nausea, and vomiting while very agitated and depressed. It may
have been beneficial and appropriate to request a social work or psychiatry consult.
If he was able to express his feelings differently than it is possible JL would have
been more positive and willing to try different tube feeding formulas. The formulas
he did not try were Boost High Protein, Jevity 1.0, and Vital 1.5. We did take time to
explain to him our reasoning behind choosing each formula for him to try. The
physicians were also encouraging him to use his jejunostomy tube, but they did not
have much luck. I felt that the physicians and nurses that were working with JL were
doing their best to encourage JL when he was there for treatment. There was
definitely team work surrounding his care and it was great to experience the team
environment at the MD Anderson Cancer Center.
In addition to difficulty with tube feeds, JL was not eating much by mouth.
While we did encourage him to eat as much as possible we did not give him an
actual list of foods for him to try. Looking back I believe providing JL with a physical
list could have been beneficial. Since he was experiencing some difficulty and pain
with swallowing, giving him a list of soft foods could have expanded his variety and
helped him to eat more. There are many foods the list would have included: cream

39
of wheat, grits, scrambled eggs, oatmeal, applesauce, ice cream, milk shakes, JellO, pudding, yogurt, bananas, other soft fruits, well-cooked vegetables, soft cheeses,
pastas, and soups. Some other methods to cope with this side effect we could have
discussed in more detail would be eating moist foods, avoiding citrus, caffeine,
tomatoes, vinegar, and hot peppers, maintaining good oral hygiene, and eating
foods at room temperature. Overall, JLs course of treatment was tough, but the
support system he had at home and at the MD Anderson Cancer Center helped to
get him where he is today. Hopefully, he will be getting an esophagectomy in the
near future.

Summary
Overall, JLs journey had many bumps in the road. He did complete his
chemotherapy course and completed almost all of his scheduled radiation. The side
effects of his cancer and his treatments greatly affected him in terms of nutrition. JL
lost a total of 89 pounds and as much as we tried to prevent further weight loss his
stubbornness and anger got in the way. His refusal to use his jejunostomy tube
coupled with his decreased intake due to pain when swallowing where the two
biggest factors in his weight loss. Clinically, JL was doing well with his treatment and
was still scheduled to follow up with a surgeon to schedule an esophagectomy.

40
In the end, JL cancelled his appointment with the surgeon and I am unsure if
he ever rescheduled. I have followed up and am waiting to hear back. If JL had been
willing to try different formulas to use with his jejunostomy tube he may have been
able to maintain his weight better. Drinking small amounts of water and eating soup
were clearly not enough to meet his needs. Ideally, we could have met his needs
and maintained his weight throughout treatment in order to be more prepared for
surgery. However, everyones cancer is different and this is how the side effects
presented for JL. He is currently still in the care of doctors at Cooper University
Hospital and the MD Anderson Cancer Center.

References
1. National Cancer Institute. SEER Stat Fact Sheets: Esophageal Cancer.
http://seer.cancer.gov/statfacts/html/esoph.html. Accessed December 14,
2014.
2. American Cancer Society. Cancer Facts and Figures 2014.
http://www.cancer.org/acs/groups/content/@research/documents/webcontent/
acspc-042151.pdf. Published 2014. Accessed December 14, 2014.

41
3. Medscape. Esophagus Anatomy.
http://emedicine.medscape.com/article/1948973-overview. Updated October
14, 2011. Accessed December 14, 2014.
4. American Cancer Society. What is cancer of the esophagus?
http://www.cancer.org/cancer/esophaguscancer/detailedguide/esophaguscancer-what-is-cancer-of-the-esophagus. Updated November 6, 2014.
Accessed December 14, 2014.
5. National Cancer Institute. What You Need to Know About Cancer of the
Esophagus. http://www.cancer.gov/publications/patienteducation/esophagus.pdf. Updated March 2013. Accessed December 14,
2014.
6. American Cancer Society. What are the risk factors for cancer of the
esophagus?
http://www.cancer.org/cancer/esophaguscancer/detailedguide/esophaguscancer-risk-factors. Updated November 6, 2014. Accessed December 14,
2014.
7. National Cancer Institute. Alcohol and Cancer Risk.
http://www.cancer.gov/cancertopics/factsheet/Risk/alcohol. Updated June 24,
2013. Accessed December 14, 2014.
8. Long E and Beales ILP. The role of obesity in oesophageal cancer
development. Ther Adv Gastroenteral. 2014;7(6):247-268.
9. Alexandre L, Long E, and Beales ILP. Pathophysiological mechanisms linking
obesity and esophageal adenocarcinoma. World J Gastrointest Pathophysiol.
2014;5(4):534-549.
10.Mayo Clinic. Barretts Esophagus. http://www.mayoclinic.org/diseasesconditions/barretts-esophagus/basics/definition/con-20027054. Published
August 7, 2014. Accessed December 14, 2014.
11.American Cancer Society. Signs and symptoms of esophagus cancer.
http://www.cancer.org/cancer/esophaguscancer/detailedguide/esophagus-

42
cancer-signs-and-symptoms. Updated November 6, 2014. Accessed
December 14, 2014.
12.Merck Manuals. Esophageal Cancer.
http://www.merckmanuals.com/professional/gastrointestinal_disorders/tumors
_of_the_gi_tract/esophageal_cancer.html. Updated July 2014. Accessed
December 14, 2014.
13.American Cancer Society. How is cancer of the esophagus diagnosed?
http://www.cancer.org/cancer/esophaguscancer/detailedguide/esophaguscancer-diagnosis. Updated November 6, 2014. Accessed December 14, 2014.
14.MedlinePlus. Upper GI and small bowel series.
http://www.nlm.nih.gov/medlineplus/ency/article/003816.htm. Updated
October 8, 2012. Accessed December 14, 2014.
15.Kosovec JE, Zaidi AH, Komatsu Y, Kasi PM, Cothron K, Thompson DV, Lynch E,
and Jobe BA. Establishing magnetic resonance imaging as an accurate and
reliable tool to diagnose and monitor esophageal cancer in a rat model. PLOS.
2014;9(4):e93694.
16.Lab Tests Online. Complete Blood Count.
http://labtestsonline.org/understanding/analytes/cbc/tab/sample/. Updated
September 15, 2014. Accessed December 14, 2014.
17.National Cancer Institute. Understanding Laboratory Values.
http://www.cancer.gov/cancertopics/factsheet/detection/laboratory-tests.
Updated December 11, 2013. Accessed December 14, 2014.
18.American Cancer Society. How is cancer of the esophagus staged?
http://www.cancer.org/cancer/esophaguscancer/detailedguide/esophaguscancer-staging. Updated November 6, 2014. Accessed December 14, 2014.
19.Medscape. Esophageal Cancer Staging.
http://emedicine.medscape.com/article/2003224-overview. Updated
September 6, 2013. Accessed December 14, 2014.
20.American Cancer Society. How is cancer of the esophagus treated?
http://www.cancer.org/cancer/esophaguscancer/detailedguide/esophagus-

43
cancer-treating-general-info. Updated November 6, 2014. Accessed
December 14, 2014.
21.Miller KR and Bozeman MC. Nutrition therapy issues in esophageal cancer.
Curr Gastroenterol Rep. 2012;14:356-366.
22.American Cancer Society. Targeted therapy for cancer of the esophagus.
http://www.cancer.org/cancer/esophaguscancer/detailedguide/esophaguscancer-treating-targeted-therapy. Updated November 6, 2014. Accessed
December 14, 2014.
23.Tew WP, Kelsen DP, and Ilson DH. Targeted therapies for esophageal cancer.
Oncologist. 2005;10(8):590-601.
24.American Cancer Society. Endoscopic treatments for cancer of the
esophagus.
http://www.cancer.org/cancer/esophaguscancer/detailedguide/esophaguscancer-treating-endoscopic-treatments. Updated November 6, 2014.
Accessed December 14, 2014.
25.Nutrition Care Manual. Esophageal.
http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=145164. Accessed
January 19, 2015.
26.Evidence Analysis Library. Oncology. https://www.andeal.org/topic.cfm?
cat=2959&conclusion_statement_id=250683&highlight=esophageal
%20cancer&home=1. Updated 2007. Accessed January 19, 2015.
27.Ligthart-Melis GC, Weijs PJM, te Boveldt ND, Buskermolen S, Earthman CP,
Verheul HMW, de Lange-de Klerk ESM, van Weyenberg SJB, van der Peet DL.
Dietician-delivered intensive nutritional support is associated with a decrease
in severe postoperative complications after surgery in patients with
esophageal cancer. Diseases of the Esophagus. 2013;26:587-593.
28.Nutrition Care Manual. Oncology General Guidance.
http://www.nutritioncaremanual.org/topic.cfm?
ncm_category_id=1&lv1=22938&lv2=255467&ncm_toc_id=255467&ncm_he

44
ading=Nutrition%20Care#ComparativeStandards. Accessed January 19,
2015.
29.Wu J MD PhD, Huang C MHS, Xiao H MD PhD, Tang Q MD, Cai W MD PhD.
Weight loss and resting energy expenditure in male patients with newly
diagnosed esophageal cancer. Nutrition. 2013;29:1310-1314.
30.Mahan KL, Escott-Stump S, Raymond JL. Krauses Food and Nutrition Care
Process. 13th ed. St. Louis, MO: Elsevier Saunders; 2012:842-854.
31.Nutrition Care Manual. Esophageal Surgery Nutrition Therapy.
http://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=129.
Accessed January 19, 2015.
32.Miller KR, Bozeman MC. Nutrition therapy issues in esophageal cancer.
Current Gastroenterology Reports. 2012;14:356-366.
33.Starr, B, Davis S, Ayala-Peacock D MD, Blackstock WA MD, Levine EA MD.
Reassessment of the role of enteral tube feedings for patients with
esophageal cancer. American Surgeon. 2014;80(8):752-758
34.Kobayashi K, Koyama Y, Kosugi S, Ishikawa T, Sakamoto K, Ichikawa H, Wakai
T. Is early enteral nutrition better for postoperative course in esophageal
cancer patients? Nutrients. 2013;5:3461-3469.
35.Malone A. Enteral formula selection. In: Charney P, Malone A, eds. ADA Pocket
Guide to Enteral Nutrition. Chicago, IL: American Dietetic Association; 2006.
36.Ryan AM, Reynolds JV, Healy L, Byrne M, Moore J, Brannelly N, McHugh A,
McCormack D, Flood P. Enteral nutrition enriched with eicosapentaenoic acid
(EPA) preserves lean body mass following esophageal cancer surgery: results
of a double-blinded randomized controlled trial. Annals of Surgery.
2009;249(3):355-363.
37.Fietkau R MD, Lewitzki V MD, Kuhnt T MD, Holscher T MD, Hess CF MD PhD,
Berger B MD, Wiegel T MD, Rodel C MD, Niewald M MD, Hermann RM MD,
Lubgan D PhD. A disease-specific enteral nutrition formula improves
nutritional status and functional performance in patients with head and neck

45
and esophageal cancer undergoing chemoradiotherapy: results of a
randomized, controlled, multicenter trial. Cancer. 2013;119:3343-3353.
38.American Society of Parenteral and Enteral Nutrition Board of Directors and
the Clinical Guidelines Task Force. Guidelines for the use of parenteral and
enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr.
2002;26(suppl 1):1SA-138SA.
39.Seike J, Tangoku A, Yuasa Y, Okitsu H, Kawakami Y, Sumitomo M. The effect of
nutritional support on the immune function in the acute postoperative period
after esophageal cancer surgery: total parenteral nutrition versus enteral
nutrition. The Journal of Medical Investigation. 2011;58:75-80.

Figure 1: http://quizlet.com/2198099/digestive-system-flash-cards/
Figure 2: https://www.jhmicall.org/GDL_Disease.aspx?
CurrentUDV=31&GDL_Cat_ID=83F0F583-EF5A-4A24-A2AF0392A3900F1D&GDL_Disease_ID=0E11DE8C-7FB7-47AE-BC76-766AC830F7BA
Figure 3: http://www.aboutcancer.com/pet_esophagus_sah_807.jpg
Figure 4: http://download.thelancet.com/images/journalimages/01406736/PIIS0140673612606436.gr1.lrg.jpg

46
Figure 5: http://www.randeepwadhawan.com/eesophagectomy-cancer-of-theoesophagus/
Figure 6: http://cancerinfo.tri-kobe.org/Media/EN/CDR0000433292.jpg
Figure 7: http://www.andeal.org/topic.cfm?cat=1225
Figure 8 & 9: http://patients.gi.org/topics/enteral-and-parenteral-nutrition/

Appendix
Medication Bibliography
Medication
Carafate 100
mg/mL

Indication
Antiulcer;
gastric
mucosa
protectant

Side Effects
Constipation, cramps;
caution with dysphagia,
delayed gastric emptying,
or tube feeds possible
bezoar formation due to
protein-binding properties

Patient Education
Take with water on
an empty stomach
1 hour before
meals. Take calcium
or magnesium
supplements
separately by 30

47

Zofran 4 mg,
Compazine 10
mg

Antiemetic,
antinausea
nt,
antipsychot
ic

Esomeprazole
magnesium 20
mg

Antiulcer,
antigerd

Oxycodone
(Percocet) 5-325
mg, oral

Narcotic

Roxicodone 5
mg

Narcotic

Increased appetite, weight

gain, dry mouth, nausea,
vomiting, constipation,
sedation, blurred vision, dry
eyes, restlessness,
drowsiness, dizziness,
hives, tachycardia,
headache, edma, jaundice,
rash, fever, syncope,
hypotension, urinary
retention, decreased WBC,
alterations in blood glucose
May decrease absorption of
iron and vitamin B12,
increase gastric pH,
nausea, abdominal pain,
diarrhea, headache,
dizziness, cough, rash,
muscle/back pain, increase
blood glucose levels
Anorexia, dry mouth,
dyspepsia, gastritis,
nausea, vomiting, diarrhea,
constipation, drowsiness,
sedation, fatigue, dizziness,
weakness, itching,
sweating, fever/chills,
hypotension, headache,
nervousness, confusion,
urinary retention
Anorexia, dry mouth,
dyspepsia, gastritis,
nausea, vomiting, diarrhea,
constipation, drowsiness,
sedation, fatigue, dizziness,
weakness, itching,
sweating, fever/chills,
hypotension, headache,
nervousness, confusion,
urinary retention

minutes or more.
Avoid or limit
alcohol.
May take with food
or water to
decrease GI
distress. Take
magnesium
supplement
separately by 2
hours. Limit
caffeine. Avoid
alcohol.

Take 30-60 minutes

before a meal. May
need a calcium
supplement. Avoid
gingko and SJW.
Avoid alcohol.

May take with food

to decrease GI
distress. Caution
with grapefruit and
related citrus. Avoid
alcohol.

May take with food

to decrease GI
distress. Caution
with grapefruit and
related citrus. Avoid
alcohol.

Laboratory Values
9/9/2014

9/16/201

9/23/14

10/2/201

10/9/201

10/16/20

48
4
CHEM PROFILE
Glucose
94
BUN
7
Creatinin
0.89
e
Sodium
140
Potassiu
4.4
m
Chloride
101
CO2
27
Calcium
9.6
Albumin
4.5
eGFR
109
nonAA
BUN/Crea 8
t Ratio
CBC
WBC
7.6
RBC
4.87
Hemoglo
14.9
bin
Hematocr 44.1
it
MCV
91
MCH
30.6
MCHC
33.8
RDW
13.4
Platelet
383
Count
DIFFERENTIAL
Neutrophi 67
ls
Basophils 0
Lymphs
24
Monocyte 4
s

14

88
7
0.84

126
9
0.65

107
6
0.69

91
7
0.64

85
9
0.74

139
4.2

138
4.0

141
4.1

141
4.4

142
4.5

100
27
9.5
4.5
111

101
24
9.3
4.5
123

102
25
9.6
4.5
120

103
26
9.2
4.2
124

103
26
9.5
4.4
117

14

11

12

7.9
4.85
15.1

6.6
4.65
14.1

4.5
4.64
14.2

4.0
4.13
12.7

3.5
4.6
12.3

43.4

41.7

41.4

36.7

36.6

90
31.1
34.8
13.5
430

90
30.3
33.8
13.5
308

89
30.6
34.3
13.6
235

89
30.8
34.6
13.8
205

90
30.3
33.6
14.2
189

67

80

81

81

82

0
21
7

0
14
2

0
8
7

1
11
6

0
10
7

49
Terminology
Acid reflux a condition in which gastric fluid is brought up into the esophagus
Adenocarcinoma a type of cancer that forms in mucus secreting glands
Adipocytes cells that primarily make up adipose tissue that stores energy as fat
Adventitial layer the outermost connective tissue covering an organ or vessel
Alcohol dehydrogenase a group of enzymes that aid in the conversion between
alcohols and aldehydes or ketones
Anastomotic leak a postsurgical complication where there is breakdown at the site
of closure
Anemia a deficiency of red blood cells or hemoglobin in the blood
Anorexia a loss of appetite
Barretts esophagus a disorder in which the lining of the esophagus is damaged
due to stomach acid
Basophils a type of white blood cell
Biopsy removal of tissue for examination
Carboplatin a chemotherapy drug
Chemotherapy treatment of cancer using chemical substances
Docosahexaenoic acid an omega-3 fatty acid
Dumping syndrome a group of symptoms that present from rapid gastric emptying
Dysphagia difficulty swallowing
Dysplasia abnormal growth or development of organs or cells
Eicosapentaenoic acid an omega-3 fatty acid
Endoscopic mucosal resection a procedure to remove cancerous or abnormal
tissue from the gastrointestinal tract

50
Endoscopy a test that uses a flexible, narrow tube with a camera to look inside the
body
Enteral nutrition a way to deliver nutrition via the stomach or small intestine
Eosinophils a type of white blood cell
Esophagectomy surgery to removal part or the entire esophagus
Fistula an abnormal or surgically made passage between hollow organs or
between the body surface and a hollow organ
Gastroesophageal junction the point where the distal esophagus meets the
proximal stomach
Gastroesophageal reflux disease a chronic regurgitation of acid from the stomach
into the esophagus
Gastroparesis a condition in which gut motility does not function normally
Heliobacter pylori a bacterium that causes gastritis and ulcers in the stomach and
duodenum
Hematocrit the ratio of the volume of red blood cells to the total blood volume
Hemoglobin a type of red blood cell that transports oxygen in the blood
HER2 human epidermal growth factor receptor 2; a protein that plays a role in the
development of cancer
Indigestion pain or discomfort related to difficulty digesting food
Jejunostomy tube a tube surgically inserted through the abdomen and into the
jejunum used for enteral nutrition
Leptin a protein produced by fatty tissue that regulated fat storage
Lymphocytes a type of white blood cell
Lymphoma a type of cancer that occurs in the lymph nodes
Melanoma a type of cancer that begins in melanocytes

51
Metastasis the development of secondary malignant growths apart from the
primary cancer site
Monocytes a type of white blood cell
Mucosal layer the absorptive and secretory layer of the gastrointestinal tract
containing the glands
Mucositis painful inflammation and ulceration of the mucous membrane layer
lining the gastrointestinal tract
Muscular layer a thin layer of smooth muscle found in most parts of the
gastrointestinal tract
Neutrophils a type of white blood cell
Odynophagia painful swallowing
Photodynamic therapy a type of cancer treatment that uses a photosensitizing
agent exposed to a specific wavelength of light to produce oxygen and kill nearby
cells
PICC line peripherally inserted central catheter; a form of long term intravenous
access
Platelets a cell fragment found in the blood that assists with clotting
Pro-inflammatory cytokines a cytokine that supports systemic inflammation
Proteolysis-inducing factor a cachectic factor that can be detected in the urine of
cancer patients undergoing weight loss
Radiation therapy treatment of cancer using x-rays or other forms of raditation
Red blood cells a disk-shaped, biconcave cell in the blood that carries oxygen and
carbon dioxide to and from tissues
Resting energy expenditure the amount of energy required for 24 hours by the
body during resting conditions

52
Sarcoma a type of cancer that occurs in connective or other nonepithelial tissue
Squamous cell carcinoma a type of cancer that occurs in epithelial cells
Stent a temporary support placed inside a blood vessel or other canal to release
an obstruction
Stricture an abnormal narrowing of a tube or canal
Submucosal layer a layer of dense irregular connective tissue that supports the
mucosal layer in the gastrointestinal tract
Taxol a chemotherapy drug
Thrombocytopenia a deficiency of platelets in the blood causing bleeding
Total parenteral nutrition - a way to deliver nutrition via intravenous access
Upper gastrointestinal series a test that produces a series of x-ray images of the
esophagus, stomach and duodenum
VEGF vascular endothelial growth factor; a signal protein that stimulates
vasculogensis and angiogensis
White blood cells a colorless cell that helps to fight infections
Xerostomia dry mouth