Gastrointestinal Cancer

Incidence of Gastrointestinal cancer has increased in the recent past. Upper GI Cancer include cancer of the esophagus, stomach, duodenum and small intestine. Cancer of the colon and rectum are lower GI cancer. Hepato-Biliary GI Cancer include cancer of the liver, gallbladder, bile duct and pancreas. Management of GI Cancer include team work of GI Oncosurgeon/Medical Oncologist/Radiation Oncologist/Gastroenterologist

Symptoms of Gastrointestinal Cancer

Dysphagia: Early and common symptom of esophagus cancer. Patient has initially dysphagia to solid foods and gradually progress to liquid. This progressive dysphagia is indicative of any progressive mass lesion which is compromising the esophagus lumen and causing dysphagia

Vomiting: It occurs when there is an obstruction in the gastro-intestinal tract. Obstruction distal to the bile duct opening causes billious vomiting. Obstruction proximal to it causes non-billious vomiting. Primary stomach cancer or small bowel cancer causes vomiting due to intrinsic mass which compromise the lumen. Gallbladder Cancer can cause external compression over the duodenum and antro-pyloric region resulting in gastric outlet obstruction

Jaundice: It occur when there is obstruction in the Common bile duct. This obstruction can be intrinsic due to bile duct cancer. It may be extrinsic due to external compression such as Gallbladder mass or pancreatic head mass causing external compression over the CBD. Patient present with features of surgical obstructive jaundice such as pale colored stool, dark urine and pruritus

Melena: It is passage of black tarrish colored stool. Melena indicate slow bleed in the GI tract. This bleed can originate at any site along the GI tract. Cancer stomach and peri-ampullary cancer and right sided colon cancer have a tendency to bleed. Sometimes patient have occult bleed and present with feature of anemia such as weakness/tiredness

Hematochezia: It is the passage of fresh blood per rectum. Small amount of fresh blood with stool indicate cancer rectum

Anorexia and Weight Loss: these are common symptoms of any malignancy in our body

Diagnosis & Investigations
Upper GI Endoscopy is done for esophagus, stomach and duodenal cancer.Colonoscopy for Colo-Rectal Cancer. Triple Phase CT abdomen for Liver, Gallbladder and Pancreas Cancer. PET-Scan is also helpful

Definitive Treatment

Gall-Bladder: Radical cholecystectomy in which gallbladder is removed along with liver wedge and lymphadenectomy is done if the tumor is resectable. Cystic duct margin is sent for biopsy intra-op. If biopsy comes to be positive then Common Bile duct excision along with Roux-en-Y Hepaticojejunostomy is done

Liver: Options are Surgery, Local ablative procedures and chemotherapy. Surgery is the preferred one.There are two options in surgery one is liver transplant and other is liver resection. Liver transplant is preferred in those patients who have liver cancer on background of chronic liver disease as the chances of recurrence after liver resection is high in these patients. In 20% patients liver cancer develop on background of normal liver.Liver resection is the treatment of choice in these patients. Local ablative procedures are done when patient is not fit for surgery or as a bridge to liver transplant

Pancreas:The standard surgical procedure done in case of tumor located in head of pancreas is whipple procedure (pancreatico-duodenectomy). If it is located in the distal part distal pancreatectomy with splenectomy is done. Patient with a head tumor can have jaundice. Pre-operative biliary stenting is done if the bilirubin level is very high, patient has fever and poor general condition with poor nutrition. Most of the medical oncologist advice pre-operative chemotherapy in locally advance pancreatic cancer

Esophagus: Radical Esophagectomy is done in which esophagus is removed and a stomach tube is created which is anastomosed to esophagus in the neck

Stomach: Radical gastrectomy is done. Depending on the location of tumor radical distal gastrectomy or radical sub-total gastrectomy or radical total gastrectomy is done. At least 12 lymph nodes should be dissected in the resected specimen for completeness of lymphadenectomy

Colo-Rectal: The standard surgical treatment of colon cancer is radical colectomy. Colon is divided into four parts, ascending or right colon, transverse colon, descending or left colon and sigmoid colon. Depending on location of cancer respective colectomy is done. After colonic resection depending on patient nutrition status and tumor burden either anastomosis is done or stoma is created. For Rectal cancer Anterior Rescetion is done. For Locally advanced rectal cancer pre-operative chemo-radiotherapy is given medical oncologist, which has shown to increase the survival rate

Laparoscopic GI Cancer Surgery

Laparoscopic surgery was initially done for benign gastrointestinal diseases. With advance in technology and instrumentation it was further extended for cancer surgery also. Now there is lot of data in literature which suggest that laparoscopic surgery in cancer patients is safe as open surgery. Long term survival rate in cancer patients in laparoscopic surgery is also same as open surgery. GI Cancer surgeon who have special training in Laparoscopic surgery do GI Cancer surgery laparoscopically. Advantages of laparoscopy surgery is minimal pain and early recovery

Palliative Treatment

Surgery is the treatment of choice in gastrointestinal cancers if the tumor is resectable and patient is fit for surgery. Gastroenterologist play an important role if the tumor is advanced and metastatic, as most of these symptoms can be palliated endoscopically

Dysphagia is the most common symptom of esophagus cancer and the best way of palliation is endoscopic placement of esophagus stent across the site of obstruction.In similar way in patients of stomach cancer and duodenal cancer who have gastric outlet obstruction and have vomiting, stent can be placed across the obstruction site and vomiting can be relieved. Patients of esophagus and stomach cancer can present with hematemesis or melena. It indicate tumor site bleed. Many a times these bleeds can be controlled endoscopically

Growth in the colon or rectum can cause bowel obstruction.Many a times these patients present in emergency with features of large bowel obstruction such as abdomen distension, vomiting, not passage of flatus and motion. When investigated further are found to have advanced colo-rectal cancer. In these patients endoscopically stent can be placed and obstruction can be relieved. A major surgery can be avoided in these patients

Most common hepato-biliary cancer symptom which require palliation is jaundice. Jaundice is either due to primary cancer such as cholangiocarcinoma or it may be caused by external compression by nearby organ malignancy. Gallbladder neck mass, periampullary cancer, pancreatic head mass malignancy are common GI Cancer which can cause jaundice.Endoscopic internal biliary stenting is best palliation for these patients

Doctors Involved in Treatment of GI Cancer

Surgical Gastroenterologist are GI Cancer Surgeons or GI Oncosurgeons are trained in the field of GI Surgery. They have vast experience in surgical management of these patients

Medical Gastroenterologist have role from diagnosis to palliative care of these patients. Upper GI Endoscopy or Colonoscopy make the diagnosis. Endoscopic placement of stent in the esophagus, CBD and rectum provide symptomatic relief in advance cancer

Medical Oncologist are specialized physicians for medical management of cancer who give chemotherapy. It may be given in the pre-operative period in locally advance tumors to make it resectable. After surgery to increase the survival rate or in metastatic disease as palliation. There are some tumors which respond to radiation. In these cancers, Radiation Oncologist is involved to provide his expertize