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Medicine 2

Gastrointestinal Malignancies and Emergencies


Dr. Mapalla
3rd shifting / Nov. 7, 2008
Trans group: Carmen Soo, Jon Avila, et. al.

GASTROINTESTINAL MALIGNANCIES
Initial Phase (20 years or more)
Esophageal CA • Basal cell hyperplasia
• Various degrees of hyperplasia
Epidemiology -mild dysplasia develop SCC
• No other cancer whose incidence varies within -14.9% of severe dysplasia developed SCC in 1-
countries as much as esophageal CA 12 years
• Half of all cases in China
• Equal male:female ratio in endemic areas Developing Phase (33.9 to 74 months)
• Squamous cell CA and adenocarcinoma more • When severe dysplasia become early carcinoma
than 95% of esophageal tumors
Overt Phase
• 6th-7th decade of life
• Mean survival time 9.7 months
Risk factors and Pre-existing conditions associated with
Clinical Manifestations
Squamous Cell Carcinoma
• Vague retrosternal discomfort
• Dietary (N-nitroso compounds, alcohol
(liquor>beer), hot tea, tannins) • Dysphagia
• Tobacco • Food intolerance
• Betel nut chewing • Anorexia
• Chronic strictures (lye, radiation) • Weight loss
• Chronic infection (fungal, viral) • Odynophagia and back pains
• Chronic esophagitis • Hoarseness
• History of head and neck malignancy • Hematemesis
• Achalasia
Diagnostic Evaluation
• Plummer-Vinson syndrome
• Tylosis Laboratory Data
• Celiac disease • Microcytic anemia
• History of gastrectomy • Low serum albumin
• History of radiation therapy • Elevated ALP
• Hypercalcemia
Pathology
• Low cholesterol
• Most common site: middle esophagus
• CA 19-9 (34% sensitivity)
• Early: barely perceptible to tiny, slightly elevated
coarse or polypoid with denuded epithelium Balloon cytology
• Histologic: intraepithelial, intramucosal,
submucosal
• Only 8-12% of SCC lesions diagnosed early
• Only 2.2% of early SCC limited to musculartis
mucosa (88.4% vs. 54.5% sub,ucosal 5 year-
survival)
• Advanced SCC: mushroom-like, ulcerative,
stenotic polypoid

Spread and Metastasis


• Grows by intraesophageal spread, direct
extension, lymphatic and hematogenous Early ulcerative malignancy (adenocarcinoma) of the
• Typically involves adjacent structures distal esophagus
• LN metastasis 42-67%, bidirectional
• Distant metastasis; 25-30%
• Liver, lung, bone

Natural History of SCC

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
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T2 Tumor invades muscularis propia
T3 Tumor invades adventitia
T4 Tumor invades adjacent structures

Regional Lymph Nodes

Nx Regional LN cannot be assessed


No No regional LN metastasis
N1 Regional LN metastasis

Exophytic polypoid carcinoma in the distal esophagus Distant Metastasis

Mx Presence of distant metastasis cannot be


assessed
Mo No distant metastasis
M1 With distant metastasis

Stage Grouping

Stage O TisNoMo
Stage I T1NoMo
Stage IIA T2NoMo
TsNoMo
Stage IIB T1N1Mo
T2N1Mo
Stage III T3N1Mo
Polypoid carcinoma in mid-esophagus (Barium swallow) T4AnyNMo
Stage IV AnyTAnyNM1

5 Year Survival
• I: 60.4%
• II:31.3%
• III:19.9%
• IV:4.1%

Treatment Modalities

• Surgery
• Radiation
• Chemotherapy
• Multimodality
-preoperative radiotherapy
-preoperative chemotherapy
-preoperative chemoradiation
-preoperative radiotherapy, chemotherapy
• Endoscopic modality

Endoscopic Ultrasound in Esophageal Carcinoma

TNM Staging for Esophageal CA

Primary Tumor

Tx Primary tumor cannot be assessed Waisting due to stricture


To No evidence of primary tumor
T1 Tumor invades lamina propia or submucosa
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
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•Gastric adenomatous polyps
•Barrett’s esophagus

Tumors of the Stomach

Benign
•Polyps
•Hyperplastic
Celestin semi-rigid esophageal dilators •Fundic gland
•neoplastic
•multiple tumors
•leiomyomas
•lipomas
•heterothropic pancreas

Malignant Tumors
•Carcinomas
•Lymphomas
•Sarcomas
•Carcinoids
Following balloon dilatation, wasting is effaced
Gastric Polyps

Hyperplastic polyps
•Most common type of polyp(65-90%)
•Inflammatory or regenerative polyps in reaction to
chronic inflammation or regenerative hyperplasia
•Often found in HP infection
•Sessile and seldom pedunculated
•Mostly in the antrum
•Multiple in 50% of cases
Expandable metal stent on an inoperable carcinoma •Varying in size but seldom <2cm
•Rate of malignant transformation 1-3%
Esophageal AdenoCA •Usually larger than 2 cm

•Frequency 8-33% of esophageal malignancy Fundic Gland


•Affected patients in mid sixties
•Barrett’s esophagus single most important risk factor Types:
•Tubular
•Villous (often >2 cm and malignant)
•Macroscopically
•More often in antrum
•Pedunculated with malignant potential
•Solitary, large and ulcerated

Treatment
•Endoscopic removal if no malignancy identified with
surveillance
•Excision with malignant focus or were the endoscopic
removal failed
Risk Factors for Gastric CA
Multiple Gastric Polyps
 Precursor conditions:
•Chronic atropic gastritis and intestinal metaplasia •Rare condition
•Pernicious anemia •Adenomatous and hyperplastic polyps
•Partial gastrectomy for benign disease •20% incidence of adenocarcinoma
•H. pylori infection
•Menetrier’s disease Treatment
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Topic: GI Malignancies and Emergencies
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•If confined to corpus and antrum- distal gastrectomy •Involvement of fundus and cardia
•If otherwise total gastrectomy
•Sometimes associated with polyposis syndrome Gastric Leiomyoma
•FAP
•Gardner •Incidence of 16% In autopsy
•Peutz-Jeghers
Pathology
•Cowdens
•Arise from the smooth muscle of the GIT tract
•Cronkhite Canada
•Difficult to distinguished from GIST
Gastric Lipoma •75% benign
•Differentiated only by mitotic index
•Rare subcutaneous lesions •Large protruding lesions with central ulcers
•Asymptomatic •Usually presents with bleeding if at all
•On routine endoscopy •Treatment Is local excision with 2-3cm margins
•Requires no treatment
Histologic typing
•Pillow sign
Ulcerated carcinoma (25%)
Heterotropic Pancreas •Deep penetrated ulcers with shallow edges
•Usually through all layers of the stomach
•Extopic pancreas
PolypoidCa(25%)
•Most commonly found in the stomach
•Intramural tumors, large in size
•Within 6 cm from the pylorus
•Late metastasis
•Also in meckel’s diverticulum
•Rarely larger than 4 cm
Superficial spreading Ca( 15%)
•Sessile and rubbery •Confinement to mucosa and submucosa
•Submucosal in location •Metastasis 30% at time of diagnosis
•Histological identity similar to normal pancreas •Better prognosis stage for stage
Malignant Linitis Plastica
•Peri-ampullar adeno Ca
•Duodenum •Varity of SS but involves all layers of the stomach
•Cholangio •Early spread with poor prognosis
•Pancreatic head Advance Ca (30%)
•Leiomyosarcomas •Partly within and outside the stomach
•Lymphomas •Represent the advanced stage of most of the
forementioned ca
Risk Factors for Gastric CA
Symptoms and signs
•Genetic and environmental Factors: •Vague discomfort difficult to distinguish from dyspepsia
o Family history of Gastric Ca •Anorexia
o Blood type A •Meat aversion
o Hereditary nonpolyposis colon Ca syndrome •Pronounced weight loss
o Low socio economic status
o Low consumption of fruits and vegetables At late stage
o Consumption of smoked, salted, poorly preserved •Epigastric mass
foods •Hematemesis usually coffee ground seldom severe
o Cigarette smoking
•Metastasis
Adenocarcinoma of the Stomach •Virchow node on the neck
•Blumer shelf in rectum
•Declining incidence In the western world
Gastric Lymphoma
•HP associated due to chronic atropic gastritis
•Also related to Low dietary intake of vegetables and
•5% of all neoplastic gastric neoplasm
fruits
•2 different types of lymphoma
•High dietary intake of starches
•Part of systemic lymphoma with gastric involvement
•Common in male (3:1)
(32%)
•Histology
•Part of primary involvement of GIT(MALT tumor)
•Invariably adeno-carcinoma
•10-20% of all lymphoma occurs in the abdomen
•SCC of the oesophagus
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
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•50% of those are gastric in nature Gastric CA

Risk factors • Regional extension: up to 90%


•HP due to chronic stimulation of MALT • Distant metastasis: up to 50%
•In early stages of disease Rx of HP leads to regression • CNS
of the disease • Supraclavicular LN (virchow’s node)
• Left axillary LN (irish node)
Treatment • Lung
•Surgical resection is the only cure • Bone
•Late presentation makes surgery futile • Liver
•Palliation controversial for Hemorrhage • Umbilical node (sister mary joseph node)
Gastric outlet • Ovaries (krukenberg tumor)
•Simple gastrectomy as effective as abdominal block • Malignant ascites
•Splenectomy often added due to direct involvement • Peritoneal dissemination
- only for very distal partial gastrectomy • Rectal shelf (bloomer’s shelf)
•rest total gastrectomy
•prognosis overall 12% 5 year survival
- 90% survival for stage 1

Treatment controversial
Surgical treatment for patients without systemic
involvement
•Mandatory for high grade lesions
•Possible not needed for low grade tumor
•Total gastrectomy and en-block for direct involvement
•Sparing duodenum and oesophagus

Palliative Resection with intra abdominal spread Barium swallow polypoid carcinoma
•Good for bleeding, obstruction and perforations
•Radiation and chemotherapy combination for most

Gastric Sarcoma

•1-3% of gastric malignancies


•Include a wide variety of tumors
•Leiomyosarcoma
•Leiomyoblastoma
•GIST

Signs and symptoms


•GI blood loss
•Early satiety
•Peptic ulcer symptoms TNM tumor Staging
•Abdominal mass or fullness
•Asymptomatic or silent
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Topic: GI Malignancies and Emergencies
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o Linitis plastica
•Low prognostic value
o Nodal involvement in early gastric Ca
o Degree of differentiation
o Stromal fibrosis
o Age of patient
o Gender

Surgical Resection for Gastric adenoma


Curative 5 year survival
•All gross dx
removed margins 30%
negatively
Non curative
•Incomplete tumor
excision w/ either
residual gross tumor 5%
Endoscopic appearance of gastric carcinoma or margins involves

•Other treatment modalities


o Palliative
o Chemotherapy
o Radiation
o Adjuvant and neoadjuvant therapy

Gastric Lymphoma

•Primary: no palpable LAD, normal PBS and BM exams


o No mediastinal LAD by CXR
o Lymphoma limited to GIT according to imaging
or laparotomy
o No liver or spleen involvement (except by direct
extension)

Staging and Prognosis •Secondary: 50% of non-hodgkin’s lymphoma has GI


involvement
Stage 5 year survival o Stomach>intestine>ileocecal>colon
0 100%
IA 95% •Treatment
IB 82% o Surgery: 88% respectability rate
II 55% 50-80% 5 year survival rate
IIIA 30% o Radiotherapy
o Chemotherapy
IIIB 15%
IV 2% Tumors of the Doudenum

Prognostic Features Benign tumors


•Brunner’s gland adenoma
•Good prognosis •Leiomyoma
o Early gastric CA(within mucosa and submucosa) •Carcinoid
o Early TNM staging •Heterotrophic gastric mucosa
o No nodal involvement •Villous adenoma
o Respectable for cure
•Poor prognosis •Brunner’s gland adenoma
o Advance TNM staging o Small submucosal
o Non respectable for cure o Sessile and pedunculated variants
o Aneuploid tumor o Posterior wall junction D1 and D2
o Proximal stomach (upper 3rd) o Symptoms due to bleeding and obstruction
o Larged size, advance tumors
o Peritoneal involvement •Leiomyoma
o Malignant abscess o Asymptomatic
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
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CEA (>4ng/dl) 35
•Carcinoid AFP 3
o Mostly active (gastrin, SS, serotonin) CA 19-9 (>100 U/ml) 61
o Simple excision Trypsin 80
Ki-ras oncogene
•Heterotropic Gastric Mucosa mutation
o multiple small lesions
o no clinical significance Non-Invasive Imaging Studies
o risk of malignancy high (50%)
o endoscopic snaring/local excision Diagnostic Study Abnormal
Finding%
Malignant tumors Plain Abdominal X-Ray 1
•located in the descending part of the duodenum UGIS 5
•symptoms US 60
o pain, obstruction, bleeding and jaundice Std CT 90
o earlier than pancreas head Helical CT 95
Treatment MRI 90
o pancreatico-doudenectomy for localized lesion
o much better prognosis than pancreas Ca (30% 5 Invasive Imaging Studies
year survival as to 0%)
o palliative by pass procedure if not respectable Diagnostic Study Abnormal
o radiotherapy for advance disease? Finding%
ERCP 90
Pancreatic CA CT/US guided needle 90-95
aspiration
Patholgy: EUS 95
o 90% moderately differentiated mucinous
adenocarcinoma TNM Staging for Pancreatic Cancer
o 5% islet cell origin
o Rare forms: acinar cell, giant cell, epidermoid, Tx Primary tumor cannot be assessed
acanthomas, sarcomas, lymphomas, To No evidence of primary tumor
cystadenomas T1 Tumor limited to pancreas
o Grows rapidly T1a tumor <2cm greatest diameter
o Nearly universally fatal T1b tumor >2cm greatest diameter
T2 Tumor extends directly to duodenum,
Clinical symptoms bile duct, or peripancreatic tissues
o Common (>50% of patients) T3 Tumor extends directly to stomach,
Jaundice spleen, colon, adjacent large vessels
Pruritus
Abdominal pain Stage Clinical/Radiographic
Weight loss Criteria
o Rare
I Resectable (T1-T2, selected
Back/leg pains T3, NX, Mo)
Psychiatric disturbance, depression No encasement of celiac
Hematemesis/melena axis or SMA
Abdominal mass distension Patent SMPV confluence
Melena No extrapancreatic disease
Cholangitis
II Locally advanced (T3, NX-
Pancreatitis
1, Mo)
Gastric outlet obstruction
Arterial encasement (celiac
Venous thrombosis
axis or SMA) or venous
occlusion (SMV or portal
Laboratory Study
vein)
No extrapancreatic disease
Diagnostic Study Abnormal
III Metastatic (T1-3, NX-1, M1)
Finding%
Metastasis typically to the
Alkaline Phosphatase 80 liver, peritoneum, and
Total Bilirubin 55 occasionally lung
Total Protein 15
Amylase 15 Resectable Disease Criteria
Hematocrit 60 • absence of extrapancreatic disease
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
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• absence of direct tumor extension to SMA and celiac
axis
• Patent superior mesenteric-portal vein confluence
• Unresectable disease:
o Endoscopic stent placement
o Chemotherapy (gemcitabine)
o Pain control

Colonic CA

Conditions Predispose to Colon CA


• Advancing age
• Family Hx of colorectal CA or polyp
• High fat, low fiber diet
• Bowel disorders
o IBD (Ulcerative colitis, Crohn’s) Structure
o Adenomatous polyps of Benign and Malignant Polyps
o Some polyposis syndromes
o Familial colon CA syndrome Malignant Risk of Adenomatous Polyps

Distribution Correlated with:


1. Size – rate if <1cm
Cecum/Ascending Colon 25 2. Histologic architecture – villous (40% if >4cm)
% 3. Severity of dysplasia
Sigmoid 25
% Rate of Detection of Adenomatous Polyp
Rectum 20
% Rigid sigmoidoscope 60
Transverse 15 %
% 35cm flexible sigmoidoscope 40
Rectosigmoid 10 %
% 60cm flexible sigmoidoscope 55
Descending 65 %
% Colonoscope 95
%
Air-contrast BE 92
Clinical Presentation %
• Constitutional (fatigue, shortness of breath, angina) Single column BE 85
• Blood in the stools %
• Abdominal pain
• Change in bowel habits Modified Duke’s Classification

5-year Management
Apple-core Stricture of Colonic Carcinoma surviva
l after
treatm
ent (%)
A Cancer limited to 90 Polypectomy/en
mucosa or bloc resection
submucosa
B Cancer penetrates 80 En bloc
1 into but not thru resection/ ?
muscularis propia Adjuvant
B Cancer penetrates 70 Chemotx
2 thru muscularis
propia or serosa
C B1 + LN 50 En bloc
1 metastases resection/ ?
C B2 + LN 50 Adjuvant
2 metastases Chemotx
Different Patterns of Colonic Adenomatous Polyps
D Distant <30 Palliative
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
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metastases surgery, treat 3. Know underlying pathology
metastatic 4. Know treatment strategy
disease
Acute GI Emergencies
Random False-Negative Rate
Classify the site
FOBT 40
%
Sigmoidoscopy 15
%
Colonoscopy 05
%
Air Contrast BE 15
%
Single Column BE 30
1.
%
 Esophagus – acute dysphagia
Diet for FOBT  Perfusion
 Bleeding
Avoid:  Stomach/duodenum
- Red meat  Perfusion
- Aspirin, NSAIDs  Bleeding
- Peroxidase-containing foods (turnips, horse 2.
radish)  Gallbladder/Biliary Tract
- Vitamin C, citrus juices (false negative)  Cholecystitis
- Iron-containing drugs (false positive)  Cholangitis
 Obstructive jaundice
Poor Prognostic Features in Colorectal CA
 Pancreas
• Increased depth of bowel wall penetration  Acute pancreatitis
3.
• >4 nodes involved in tumor
 Small intestine
• Poorly differentiated tumor
 Intestinal obstruction
• Mucinous or signet-ring histology
 Mesenteric infarct
• Scirrhous histology
 (infectious diarrhea)
• Venous invasion  Crohn’s disease
• Lymphatic invasion  Meckel’s Diverticulum
• Perineural invasion 4.
• Aneuploidy  Large Bowel (+App)
• Bowel obstruction  Acute appendicitis
• Bowel perforation  Acute diverticulitis
• ? rectum  Lower GI bleeding
• ? right colon  Perforation
***oo, may question marks talaga ung nasa slide ni  Intestinal obstruction
doc  Uncontrolled ulcerative colitis
• Age <30 5.
• High CEA level  Peritoneal cavity
• Deletions in chromosomes 18q or 17p  Peritonitis
• Distant metastasis  Intra-abdominal abscess

Other Tumors of the GIT Esophagus

Biliary Tree: Cholangiocarcinoma I. Bleeding


Small Intestinal Tumors • Esophagitis, Mallory
Weiss, Varices
ACUTE GI EMERGENCIES • Variceal bleeding: can
ba catastrophic
Objectives: • Treatment: varices
1. Know conditions which commonly present as GI (Sengstaken tube,
emergency, according to GI site Somatostatin injection)
2. Know typical clinical presentation
Subject: Medicine 2
Topic: GI Malignancies and Emergencies
Page 10 of 11

II. Acute Dysphagia


• Presentation: cannot
swallow
• May have benign
stricture or cancer
II. Bleeding
• Triggered by foods, or
• Presentation: hematemesis +/- melena
tablet
• Severity: increased
• Treatment: remove
PR>90
bolus, deal with
: Fall BP<100
underlying
esophageal disease • Causes: DU, erosions, GU
• Treatment: transfusion,
inject DU

III. Perforation

High Mortality
• May folloe
endoscopy
• Presentation- acute
Gallbladder/Biliary Tract
chest/abdominal
pain
I. Obstructive Jaundice
• Air in mediastinum
• Yellow skin, sclera
and soft tissues
• Pale stools, dark urine
• Treatment:
surgery- benign • +/- pain
intubation- • +/- Courvoisier’s sign
malignant • CT: dilated bile ducts
• Establish diagnosis: gallstones, CA head of pancreas
• Appropriate treatment

II. Acute Cholecystitis


• Presentation: acute RUQ pain, +/- pyrexia, +/- rigors
Stomach/Duodenum • Diagnosis: FBC, WBCC, USS
• Treatment: antibiotics, analgesics, early surgery
I. Perforation
• Presentation: abdominal pain, rigidity, peritonitis, Pancreas
shock, air under diaphragm on x-ray
• Treatment: antibiotics, resuscitate, repair I. Acute Pancreatitis
• Constant pain, vomiting, shock
• Causes: gallstones, or alcohol
• Diagnosis: serum amylase elevation, USS
• Complications: pseudocyst, phlegmon, abscess

Small Intestine

I. Meckel’s Diverticulum
Rare
• Diverticulum of terminal
ileum
• Can be lined by gastric
epithelium
• Can perforate
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Topic: GI Malignancies and Emergencies
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• Can present like appendicitis • Underlying pathology
• Treatment strategy
II. Intestinal Obstruction
• May arise due to adhesions, hernia, tumor
• Presentation: colicky abdominal pain, vomiting,
constipation
• Treatment: resusciatate/operate

III. Mesenteric Infarct


• Sudden occlusion of small bowel arterial supply
• Sudden onset of abdominal pain, shock
• Peritonitis
• Treatment: resuscitate/operate

Large Bowel

I. Acute Diverticulitis
• Maximal in L colon
• Presentation: LIF pain, fever, tenderness,
leukocystosis
• Middle aged or elderly
• Treatment: conservative antibiotics, fluids, bed rest

II. Lower GI Bleeding


• Diverticulum, colitis
• Crohn’s tumor
• Present with Fresh Red Blood P/R
• Tendency to be more conservative than with upper
Gi
• Treatment: resuscitate, transfusion

III. Perforation
• Diverticulum, colitis, sudden severe abdominal pain,
rigidity
• Fecal peritonitis
• Pyrexia, shock
• Free gas on x-ray
• Treatment: resuscitate, operate

IV. Inflammatory Bowel Disease


• Recurrent regeneration
• Increased risk of tumor formation (14.8x)

V. Ulcerative Colitis
• Presents: bloddy diarrhea, pyrexia, leukocytosis, may
develop toxic megacolon
• Treatment: steroids, surgery on failure

Peritoneal Cavity

I. Acute Peritonitis
• Any perforation, pancreatitis, abdominal pain,
tenderness, guarding, silent abdomen, shock
• Treatment: underlying condition

Conclusion

• Conditions which commonly present GI emergency,


according to GI site
• Typical clinical presentation