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GIT (Esophageal cancer (Risk factors (tobacco and alcohol (most common…
GIT
Esophageal cancer
- 1% of all cancers
- M > F, median age 50-65 years
- Esophageal cancer metastasizes early because the esophagus lacks a serosa.
- upper(20-33%), middle(33%), lower(33-50%)
- main types:
most common worldwide: SCC in upper 2/3 of esophagus
most common in Western countries: adenocarcinoma (due to Barrett esophagus) in distal 1/3 of esophagus
Risk factors
- tobacco and alcohol (most common causes)
- hot temp. of certain beverages and foods
- esophageal stricture
- low socioeconomic status
- diet, exposure to nitrosamines
- mediastinum radiotherapy
- More than 5-10 years of GERD symptoms
- Barret metaplasia (normal squamous epithelium -->glandular columnar epithelium)
symptoms
- Dysphagia (first for solid food, then for liquids) most important
clue to the diagnosis of esophageal cancer, Odynophagia.
- Weight loss (>10% poor prognostic factor)
- Pain, Vomiting (hematemesis), Cough, Shortness of breath, anemia
- Hoarseness (involvement of recurrent laryngeal nerve) (commonly in SCC)
- Hypercalcemia
Diagnostic workup
- Upper GI endoscopy + biopsy
- EUS (endoscopic US)
- ronchoscopy ± thoracoscopy
- full metastatic workup (CXR, bone scan, CT head, CT chest / abdomen / pelvis, LFTs, etc.)
Prognostic factors
- Tumor > 5 cm
- Esophageal obstruction
- High grade
- Weight loss > 10%
Treatment
- If operable - surgery + Chemoradiation
- If medically inoperable – radical RT or RT+ CHT (cisplatin and 5-FU)
- If local treatment not possible or metastatic disease – symptomatic treatment, esophageal stent
-
lymph node involvement
- Upper 1/3-cervical nodes
- Middle 1/3-mediastinal or tracheobronchial nodes
- Lower 1/3-celiac and gastric nodes
GERD
Investigations
- clinical diagnosis is sufficient based on symptom history and relief following a trial of pharmacotherapy (PPI: symptom relief 80% sensitive for reflux)
- 24h pH monitoring
most accurate test for reflux, useful if PPIs do not improve symptoms
- esophageal manometry (study of esophageal motility)
cannot detect presence of reflux; indicated before surgical fundoplication (wrapping of gastric fundus around the lower end of the esophagus) to ensure intact esophageal function
- gastroscopy: will show nothing when there is only pyrosis (heartburn).
indications: heartburn accompanied by red-flags (bleeding, weight loss, etc.) / history suggests esophageal stricture especially dysphagia / high risk for Barrett’s (male, age >50, obese, white, tobacco use, more than 5-10 years of symptoms) / persistent reflux symptoms or prior severe erosive esophagitis after therapeutic trial of 4-8 wk of PPI 2x daily
Clinical Features
- Esophageal: Typical (epigastric heartburn (pyrosis) and acid regurgitation) / Atypical (Chest pain, Dysphagia (late), Odynophagia (rare))
- Non-esophageal: Respiratory (Chronic cough, Wheezing, Aspiration pneumonia) / Non-respiratory (Sore throat, Hoarseness, bad taste in the mouth (metallic), Dental erosions)
- Foods/Substances that Aggravate GERD Symptoms (but not the underlying disease): Caffeine, Tobacco, Fatty/fried foods, Chocolate, Spicy foods, Citrus fruit juices
Treatment
- PPIs are the most effective, need to be continued as maintenance therapy (omeprazole, lansoprazole)
- antacids (Mg(OH)2, Al(OH)3, alginate), H2-blockers (cimetidine, ranitidine)
- diet helps symptoms, not the disease; avoid alcohol, coffee, spices, tomatoes, and citrus juices
- elevating the head of bed (if nocturnal symptoms)
- Surgery:
in long-standing symptomatic disease that cannot be controlled by medical means (5% of GERD patients) (using laparoscopic Nissen fundoplication)
when complications have developed (ulceration, stenosis) (using laparoscopic Nissen fundoplication)
there are severe dysplastic changes (resection is needed)
Endocinch: using a scope to place a suture around the LES to tighten it
- Local heat or radiation of LES: causes scarring
Etiology
- relaxations of LES -- most common cause
- delayed esophageal clearance, delayed gastric emptying
- obesity, pregnancy
- acid hypersecretion (rare) from Zollinger-Ellison syndrome (gastrin-secreting tumour)
- might be associated with scleroderma
- hiatus hernia worsens reflux, does not cause it
Complications
- esophageal stricture disease–scarring can lead to dysphagia
- ulcer, bleeding
- Barrett’s esophagus and esophageal adenocarcinoma–gastroscopy is recommended for patients with chronic GERD or symptoms suggestive of complicated disease (e.g. anorexia, weight loss, bleeding, dysphagia)
- inappropriate relaxation of the lower esophageal sphincter in which the stomach contents (mostly acid) moves backwards from the stomach into the oesophagus
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