PANCE Blueprint GI and Nutrition (9%)

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

Adenocarcinoma:

  • 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 proximal (upper) 2/3rds of the esophagus
  • Progressive dysphagia, weight loss, hoarseness

DX: endoscopy + biopsy

TX: Resection

Gastric Neoplasms
Patient will present as → a 68-year-old man, who presents to your clinic with complaints of fatigue, loss of appetite, and abdominal pain/fullness. He reports a 15-pound weight loss over the last three months. Vital signs are within normal limits. On exam, you discover a firm, enlarged painless lymph node above the patient’s left clavicle. Upon further questioning, the patient reports the node has been present for the past 2 months. His stool is Guaiac positive

Abdominal pain and unexplained weight loss are the most common symptoms along with reduced appetite, anorexia, dyspepsia, early satiety, nausea and vomiting, anemia, melena, 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 – diffuse thickening of stomach wall d/t cancer infiltration (worst type)

Treatment: gastrectomy, XRT, chemo; poor prognosis

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

DX:

  • ↑ 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

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 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 antrum of the stomach, part of the duodenum, head of pancreas, gallbladder

Colon cancer
Patient will present as → a 65-year-old male with several months of weight lossvague right upper quadrant pain, and thin-caliber stools. His medical history is notable for 50-pack-years of smoking and obesity. On exam, he appears chronically ill and has firm hepatomegaly. His labs reveal a hemoglobin of 10.7 g/dL and mildly elevated ALT and AST.

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

Screening with colonoscopy begins at 50 then every 10 years until 75

  • Fecal occult blood testing – annually after age 50
  • Flexible sigmoidoscopy – every 5 years with FOB testing
  • Colonoscopy – every 10 years
  • CT colonography – every 5 years

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, CBC may show anemia

Treatment: Resect tumors and adjuvant chemotherapy

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

Rickets (ReelDx) (Prev Lesson)
(Next Lesson) Esophageal Neoplasms (Lecture)
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