PANCE Blueprint GI and Nutrition (9%)

Gastrointestinal System Neoplasms (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE Content Blueprint gastrointestinal system neoplasms (PEARLS)

Esophageal Neoplasms
Patient will present as → a 62-year-old man with a history of alcoholism who complains of difficulty swallowing solids that has progressed to difficulty swallowing liquids. He has smoked 1-2 packs of cigarettes per day for the past 38 years.  In addition, he reports occasional bouts of hematemesis and hoarseness, along with progressive weight loss and weakness.

Progressive dysphagia to solid foods along with weight loss, reflux, and hematemesis

  • Squamous cell m/c worldwide and adenocarcinoma common in the US


  • A complication of Barrett's esophagus (screen Barrett's patients every 3-5 years with endoscopy), affects distal (lower) 1/3rd of the esophagus

Squamous cell:

  • Associated with smoking and alcohol use
  • Affects the proximal (upper) 2/3rds of the esophagus
  • Progressive dysphagia, weight loss, hoarseness

DX: endoscopy + biopsy

TX: Resection

Esophageal adenoca

Endoscopic image of a patient with esophageal adenocarcinoma seen at the gastroesophageal junction.

Gastric Neoplasms
Patient will present as → a 58-year-old male chef with a history of smoking and chronic gastritis presents with a four-month history of progressive epigastric pain, occasional vomiting, and a 15-pound weight loss. He reports the pain worsens after eating, especially with spicy foods. Recently, he noticed decreased appetite and early satiety. He has no family history of gastrointestinal cancers. Physical examination reveals mild epigastric tenderness without palpable masses. You are surprised to discover a firm, enlarged, painless lymph node above the patient’s left clavicle. Laboratory tests show Guiac-positive stool and iron deficiency anemia. An upper endoscopy reveals a 3 cm ulcerated lesion in the antrum of the stomach, and a biopsy confirms adenocarcinoma.

Abdominal pain and unexplained weight loss are the most common symptoms, along with reduced appetite, anorexia, dyspepsia, early satiety, nausea and vomiting, anemia, melena, and guaiac-positive stool

  • Gastric adenocarcinoma in most cases worldwide
  • Virchow's node (Supraclavicular) (view image)
  • Sister Mary Joseph's node (Umbilical) (view image)

DX: Upper endoscopy with biopsy

  • Linitis plastica is a finding that refers to the diffuse thickening of the stomach wall due to cancer infiltration (worst type)

Treatment: Gastrectomy, radiotherapy, chemotherapy; poor prognosis


Upper endoscopy (stomach cancer)

Liver neoplasms (ReelDx)
ReelDx Virtual Rounds (Liver neoplasms)
Patient will present as → a 52-year-old female with a history of cirrhosis secondary to long-standing alcohol abuse visits your office to discuss a 15-pound weight loss over the last 6 months. She reports early satiety, jaundice, and vague abdominal discomfort. Her ascites, generally stable and small, has worsened in the last 3 weeks.

Abdominal pain, weight loss, right upper quadrant mass

  • Etiology: cirrhosis, Hepatitis B, Hepatitis C, Hepatitis D, aflatoxin from aspergillus
  • Tumor Marker: ↑ alpha-fetoprotein and abnormal liver imaging


  • ↑ Alpha-fetoprotein -  a rise in serum AFP in a patient with cirrhosis or hepatitis B should raise concern that HCC has developed
  • HCC can be diagnosed on contrast-enhanced CT, MRI, or US
    • If there are radiologic hallmarks of HCC a diagnosis of HCC is made. If the radiologic hallmarks of HCC are not seen, a biopsy should be obtained and assessed by an expert pathologist
  • Incidental liver lesions may be detected on imaging studies performed for an unrelated reason
    • Lesion characteristics and size guide further management
      • Image lesions with MRI or CT to look for imaging features of HCC. If negative, obtain follow-up ultrasounds every three months

TX: Resection, transplant - poor prognosis

CT scan of hepatocellular carcinoma, without and with IV contrast

Non-contrast and contrast CT of hepatocellular carcinoma.

Pancreatic neoplasms (ReelDx)
ReelDx Virtual Rounds (Pancreatic neoplasms)
Patient will present as → a 68-year-old smoker with a 25 lb weight loss over the last three months that is associated with a burning pain deep in the epigastrium after eating, diarrhea, and jaundice. Physical exam reveals a palpable, non-tender gallbladder and clay-colored stool. Labs show a total bilirubin of 8, alkaline phosphatase of 450, and an ALT of 150.

Painless jaundice is pathognomonic!

  • Most commonly ductal adenocarcinoma located at the pancreatic head
  • Presentation:
    • Jaundice and palpable non-tender gallbladder (Courvoisier’s sign)
    • Trousseau sign of malignancy - migratory phlebitis
    • Virchow's node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle) that is associated with pancreatic cancer

DX: Diagnose with abdominal CT scan - 75% show tumor at the head of the pancreas, 25% at the tail

  • Tumor Marker: CA 19-9

Treatment: Whipple procedure: remove the antrum of the stomach, part of the duodenum, head of the pancreas, gallbladder

Illustration of Whipple procedure

The Whipple procedure involves removing the antrum of the stomach, part of the duodenum, the head of the pancreas, and gallbladder

MBq cystic-carcinoma-pancreas

CT with IV contrast showing pancreatic adenocarcinoma at the head of the pancreas.

Colon cancer
Patient will present as → a 68-year-old male presents with a 6-month history of progressive fatigue and a change in bowel habits, including intermittent diarrhea and constipation. He also reports unintentional weight loss of 10 pounds over the last three months. He has a history of smoking but no significant family history of cancer. On examination, he appears pale, and digital rectal examination reveals occult blood. Laboratory tests show iron deficiency anemia and mildly elevated ALT and AST. A colonoscopy is performed, revealing a mass in the descending colon, and a biopsy confirms adenocarcinoma. CT scans are ordered for staging. The patient is referred to an oncologist for further management, including potential surgical resection and adjuvant chemotherapy.

Painless rectal bleeding and a change in bowel habits in a patient 50-80 years of age

  • Apple core lesion on barium enema, adenoma most common type
Screening begins at 45 and continues until 75 y/o

Recommended intervals for colorectal cancer screening tests include

  • High-sensitivity gFOBT or FIT every year
  • sDNA-FIT every 1 to 3 years
  • CT colonography every 5 years
  • Flexible sigmoidoscopy every 5 years
  • Flexible sigmoidoscopy every 10 years + FIT every year
  • Colonoscopy screening every 10 years

Selectively screen adults aged 76 to 85 years for colorectal cancer:

  • Discuss together with patients the decision to screen, taking into consideration the patient’s overall health status (life expectancy, comorbid conditions), prior screening history, and preferences.

USPSTF colorectal cancer screening guidelines

DX: Definitive diagnosis is with colonoscopy and biopsy. Barium enema will classically show an "apple core lesion"

  • More likely to be malignant: sessile, > 1 cm, villous
  • Less likely to be malignant: pedunculated, < 1 cm, tubular
  • Increased tumor Marker CEA and CBC may show anemia

Treatment: Resect tumors and adjuvant chemotherapy

An 'apple core' lesion of the colon shown on contrast enema Image by Alzaraa et al. License: CC BY 3.0

Anorectal cancer
Patient will present as → a 69-year-old male who complains of rectal pruritus, bleeding with defecation, and a sensation of incomplete evacuation. A palpable mass is noted on digital rectal examination.

Rectal bleeding + tenesmus (a feeling of incomplete emptying after a bowel movement), the most common anorectal cancer is adenocarcinoma

  • Primarily adenocarcinomas

DX: Typically, colonoscopy is done whenever rectal bleeding occurs, even in patients with obvious hemorrhoids or known diverticular disease. Coexisting cancer must be ruled out

TX: Treated with wide local surgical excision, radiation with chemotherapy for large tumors with metastases

Anal canal carcinoma 01

Carcinoma of the anal canal

Rickets (ReelDx) (Prev Lesson)
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