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Multispeciality Gallbladder Cancer Management

Gallbladder Cancer Management is team work of GI Oncosurgeon, GI Oncologist, Gastroenterologist and Intervention radiologist.Once patient is diagnosed to have gallbladder cancer further management depend on pre-operative staging of the cancer

  • Role of GI Oncosurgeon in Gallbladder Cancer Management
oncologist
Gallbladder Cancer

If the tumor is resectable, first line of management is surgery. The standard surgical procedure performed for gallbladder cancer is radical cholecystectomy. In this surgery gallbladder is removed along with liver bed and lympadenectomy is done. Staging laparoscopy is first step. There is high incidence of metastases which are missed on pre-operative imaging, which can be detected on staging laparoscopy and morbidity of long incision can be avoided

  • Role of GI Medical Oncologist in Gallbladder Cancer Management

If the cancer is metastatic on imaging then palliative chemotherapy is given. For locally advance cancer but not metastatic pre-operative chemotherapy is given to downstage the tumor and make it resectable.Once cancer seems resectable surgery is done
Chemotherapy is given in the post-op period if the tumor is beyoned certain stage

  • Role of Gastroenterologist in Gallbladder Cancer Management

Patients who are not surgical candidates either because tumor is locally advanced or metastatic or poor peformance status, these patients if have jaundice or vomitting require endoscopic palliation. Jaundice occur when the tumor compress the biliary system and vomitting occur either due to antro-pyloric or duodenal obstruction. Endoscopic Biliary and duodenal stenting is done in these patients. Jaundice and vomitting are relieved after stenting in these patients

  • Role of Intervention Radiologist in Gallbladder Cancer Management

There role comes when palliative endoscopic biliary stenting is not possible because there is complete blockage of biliary system. In these patients percutaneous transhepatic biliary drainage is done to relief jaundice

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Gastroenterologist: Role in Gastro Intestinal Cancer Sypmtoms Management

  • Best Palliative Care by Gastroenterologist for Advance GI Cancer

Surgery is the treatment of choice in gastrointestinal cancers if the tumor is resectable and patient is fit for surgery. Gastroenterologist play important role if the tumor is advanced and metastatic. These patients require treatment for there symptoms. Best way of palliation of symptoms is minimally invasive approach

Gastroenterologist
Role of Gastroenterologist in GI Cancer
  • Palliation of Upper GI Cancers Symptoms by Gastroenterologist

Dysphagia is the most common symptom of esophageal 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 vomitting, stent can be placed across the obstruction site and vomitting 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

  • Palliation of Lower GI Cancer Symptoms by Gastroenterologist

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, vomitting, 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

  • Palliation of Hepato-biliary Cancer symptoms by Gastroenterologist

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 cancer are common GI malignancy which can cause jaundice.Endoscopic internal biliary stenting is best palliation for these patients

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Gastrointestinal Cancer: An Overview

Gastrointestinal CancerThe incidence of gastrointestinal cancer is increasing. Reason being change in lifestyle, dietary habits, increased alcohol intake and smoking.The prognosis of gastrointestinal cancer patients is good if it is detected early and treated at early stage.Anorexia and weight loss are common symptom in cancer patients, along these symptoms with some GI symptoms if present should not be ignored and doctor should be consulted. There are various screening programmes for early detection of colo-rectal and liver cancer. These programmes are done for high risk patients. Screening Colonoscopy is done for patients with inflammatory bowel disease, family history of colo-rectal cancer diagnosed at early age. Regular ultrasound is done in chronic liver disease patients. Neo-adjuvant therapy for locally advance cancer of esophagus, rectum and pancreas has shown good result. Pre-operative biliary drainage is done in patients with high bilirubin who require liver resection

  • Upper Gastrointestinal Cancer

It include cancer of the esophagus, stomach, duodenum and small intestine.Dysphagia, Vomitting,melena are common symptom. Upper GI Endoscopy is helpful for diagnosis. CECT chest and abdomen for staging.

  • Lower Gastrointestinal Cancer

Cancer of the colon and rectum are lower gastrointestinal cancer. Most common symaptoms are altered bowel habits, blood in stool. Diagnosis is made by Colonoscopy. CECT abdomen for staging.MRI is done for cancer rectum There is role of Neoadjuvant therapy in locally advance rectal cancer.Surgery is the treatment of choice if cancer is resectable

  • Hepato-Biliary GI Cancer

It include cancer of the liver, gallbladder, bile duct and pancreas. Patient have symptom of right sided pain abdomen with jaundice. CECT abdomen along with MRCP is helpful to delineate biliary anatomy

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Acute Corrosive Esophagus Injury

The incidence of corrosive esophagus injury has decreased. Mostly it is accidental and seen in children. Suicidal ingestion is seen in adults. It is of two types acid and alkali. Alkali because of its adhesive property causes esophagus injury. Acid ingestion causes mainly gastric injury

  • First-aid management of Acute Corrosive esophagus injury

First step is ABC that is airway breathing circulation maintenance. If required tracheostomy should be done. Patient should be kept nil per mouth. No attempt should be done to put a ryles tube. Intravenous fluid should be started, Vitals should be monitored. No role of upper GI endoscopy at acute corrosive esophagus injury. X-ray Chest and abdomen should be done to look for pneumo-mediastinum and gas under diaphragam. If the patient condition remain stable should be allowed liquids one he is able to swallow saliva comfortably

  • Corrosive Esophagus InjuryRole of Upper GI Endoscopy in Acute Corrosive Esophagus Injury

It is a controversial issue. Some suggest that it should be done while other does not recommed upper GI endoscopy in acute injury. Upper GI endoscopy helps in grading the severity of injury. It does not change the management plan

  • Role of Surgery in Acute Corrosive Esophagus Injury

If patient general condition is good, vitals are stable and there is difficulty in swallowing after 7-10 days of ingestion then feeding jejunostomy can be done to start nutrition
If patient condition deteriorates CECT chest and abdomen should be done for esophagus and stomach or other organ perforation or necrosis. If present then damage control surgery should be done. No attempt to restore the bowel continuity should be done at this critical condition of the patient

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Hiatus Hernia: Undervalued Cause of Acid Reflux

Diaphragam is a muscular wall which separates chest cavity from abdomen cavity. Hiatus is an opening in the diaphragam through which esophagus enters from thorax into the abdomen. A hiatus hernia occur when stomach most commonly or other abdomen organs enters into thorax through this opening.

  • Types of Hiatus Hernia

There are two types of hiatus hernia one is sliding and other is paraesophageal. In sliding hernia GE junction migrates into the thorax.In Paraesophageal hernia GE junction remains stable, stomach most commonly or other abdomen organs rolls into the thorax through side of esophagus

Hiatus Hernia
Hiatus Hernia

Symptoms

Most commonly patient present with features of acid reflux such as heartburn. Heartburn is defined as pressure sensation localized to epigastric and retrosternal area which does not radiate to back.As the disease become more severe patient complain of regurgitation of digested food. Dysphagia occur due to mechanical obstruction to food.Patient may complain of chest pain

Diagnosis

Upper GI Endoscopy is first step to rule out other disorders whose symptoms mimics with hiatus hernia. It also grades the esophagus injury severity due to acid reflux. Esophagus manometery and Esophagogram are other investigations which are also done. CECT chest and upper abdomen is helpful in large paraesophagus hernia for management

Medical Treatment

Proton pump inhibitors and life style modification are first step. Pantoprazole will reduce the heartburn. Weight reduction is important. Eat small but frequent meal. Do not lie immediately after food intake

Surgical Management

Failed medical therapy, Large hiatus defect, Herniation of other abdomen organs are indications for surgery. The standard surgical procedure is reduction of hernia contents with repair of hiatus and fundoplication. It is done Laparoscopically

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Laparoscopic Abdominal Surgery: Indications

What is Laparoscopic Abdominal Surgery

It is also called as minimally invasive surgery as the length of incision used is very minimal. The advantage of Laparoscopic abdominal surgery is less pain in the psot-operatice period, early mobility of tha patient leading to early recovery. today is the era of laparoscopic surgery and most of the abdominal surgery are being performed laparoscopically

Routine Laparoscopic Abdominal Surgery

The most common abdominal surgery performed by laparosopy is cholecystectomy. It is done for symptomatic gallbladder stone disease. Another common laparoscopic surgery is appendectomy for acute appendicitis
Laparoscopy Fundoplication is done for GERD disease. A very common disorder. Life style modification is first step in management of GERD. If it fails and investigations confirm diagnosis of GERD fundoplication is done

Laparoscopic Abdominal Surgery
Laparosopic Abdominal Surgery

Laparoscopic Abdominal Surgery for Gastrointestinal Cancer

Traditional treatment for gastrointestinal cancer is open surgery. Initially it was believed that laparoscopy will be inferior to open surgery in case of gastrointestinal cancer. But as the advantages of laparoscopy surgery came out, trials were conducted in cancer surgery also. Now we have ample evidence in literature which suggest that laparoscopy surgery can be done in gastrointestinal cancer patients also, with short term advantages of laparoscopy surgery, with same long term result compared to open surgery. Most of the Colon Cancer surgery are done by Laparoscopic approach

Emergency Laparoscopic Abdominal Surgery

The most indications for emergency abdominal surgery are acute appendicitis, perforation peritonitis, intestinal obstruction and abdominal trauma. Abdominal trauma include blunt injury abdomen, stab injury, gun shot injury. If the patient condition is stable laparoscopic surgery is performed in these patients.In stab injury if patient condition is stable it acts as diagnostic laparoscopy also

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Stomach Pain: Symptoms & Investigations

Abdomen pain or stomach pain is pain or discomfort that occur between the rib cage and pelvis. It occur due to pathology in the organs situated in the abdomen cavity. It may also occur due to disease located in organs outside the abdomen cavity or some systemic cause. Abdomen pain occur due to inflammation of these organs or distension of these organs or when there is reduction in the blood supply of organs

Associated symptoms

Associated symptoms along with pain abdomen give clue that pain may occur due to disease involvement of that system. Abdomen pain along with dysuria, frequecy of urine may be due to involvement of urinary system. Vomitting alone may be non-specific. Specific cause of vomitting include gastritis most common cause, intestinal obstruction. Jaundice suggestive of liver disease, most commonly hepatitis. The cause of hepatitis may be viral hepatitis or alcohol hepatitis. Diarrhoea suggestive of colitis

Stomach Pain
Stomach Pain

Location of stomach pain

Abdomen is divided into nine quadrants. Pain located to specific quadrant may be due to inflammation or infection in the organ located in that quadrant

Blood Investigations in stomach pain

Complete blood count (CBC), Kidney function test (KFT), Liver Function test (LFT) are blood test which are helpful in stomach pain. In CBC Hemoglobin and total leucocyte count are most helpful. LFT may be deranged suggestive of hepatitis/ obstructive jaundice.KFT are deranged in chronic renal failure patients.

Radiological Investigations in stomach pain

The most common radiological investigation done for any abdomen complaint is ultrasound abdomen. It is easily available, no radiation exposure, not much expensive and non-invasive. Most common cause of abdomen pain are easily diagnosed on ultrasound. CECT abdomen is done if the findings on ultrasound are inconclusive and patient has significant pain abdomen

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Surgical Obstructive Jaundice: Causes & Treatment

What is Surgical Obstructive Jaundice

Obstruction of the bile flow into the duodenum lead to accumultion of bile pigments.As the cause of jaundice is obstruction it is called as obstructive jaundice and as it require surgical intervention it is called as surgical obstructive jaundice

Clinical Features of Surgical Obstructive Jaundice

The most prominent clinical feature which distinguish medical jaundice from surgical jaundice is pale stool in surgical jaundice. Because of obstruction bile pigments does not reach up to intestine and stools become pale. Patient complain of itching due to accumulation of bile salts in the blood

Surgical Obstructive Jaundice
Surgical Obstructive Jaundice
Liver Function Tests in Surgical Obstructive Jaundice

Total bilirubin level is raised. It is conjugated type of bilirubin which is raised in obstructive jaudice. Serum alkaline phosphatase level is raised, it indicates there is obstruction in bile passage

Radiology

Ultrasound is the first investigation to be done as it is non-invasive, no radiation exposure and readily available. Dilatation of Biliary radicles is indicative of obstructive biliopathy. Level of biliary tract dilatation is suggestive of site of obstruction. The most common cause of surgical obstructive jaundice is Common Bile duct stones. In old age patients malignancy can be the cause of  jaundice. Small CBD stones may be missed on Ultrasound.
MRI/MRCP to detect small CBD stones missed on ultrasound. Biliary anatomy is more defined on MRI.

Treatment

Vitamin K is administered to correct coagulation profile before any intervention. If patient is in cholangitis proper antibiotic and I.V fluids are administered. Specific treatment depends on the cause of CBD obstruction. The first line of treatment for CBD stones is ERCP stone clearance. Surgery is done for malignant cause of jaundice.

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Pseudocyst Pancreas: Causes, Symptoms, Diagnosis & Treatment

Pseudocyst Pancreas occur most commonly following acute pancreatitis. It occurs in chronic pancreatitis also. It is fluid collection around peri-pancreatic tissue. Following acute pancreatitis there is disruption in pancreatic duct which causes pancreatic juice to accumulate around pancreas and pseudocyst is formed. It is called as pseudocyst as there is no definitive lining of the cyst. Most of the pancreatic pseudocyts resolve following acute pancreatitis. A very few cysts persists and increase in size and causes various symptoms depending on the locations. 

Diagnosis of Pseudocyst Pancreas

Ultrasound is the fist investigation as it is non-invasive and readily available. Ultrasound will detect pseudocyst, its size and relation to surrounding structures. MRI is the investigation of choice to choose the management part. If MRI show that cyst contents are predominantly liquid that endoscopic drainage is done. If there is solid component in the cyst on MRI, then surgical drainage is best

Symptoms

When the pseudocyst compress over the surrounding structures it causes symptoms. Symptoms include pain when pseudocyst increases in size. It causes vomitting when it compress over the stomach and duodenum

Pseudocyst PancreasSurgical Management of Pseudocyst Pancreas

When the contents of the cyst are solid, Surgical management is the treatment of choice. Depending on the location of cyst either cysto-gastrostomy or cysto-jejunostomy is done. Cysto-duodenostomy is rarely done. These surgical procedures are now most commonly done by means of laparoscopy. Advantage of laparoscopy being minimal incision, less pain in the post-operative period and early recovery

Endoscopic Management of Pseudocyst Pancreas

When the cyst content is mainly in liquid form, Endoscopic management is treatment of choice. The most commonly endoscopic procedure performed is endoscopic cysto-gastrostomy

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Gallbladder Cancer Risk Factors: Are You

All Cancers have some risk factors. Some can be changed such as alcohol,obesity and smoking. Some cannot be changed like family history and age. Most of the gallbladder cancer risk factors are non-modifiable. Having a risk factor does not indicate that definitely patient will get cancer and few patients develop cancer without any risk factor
But definetly presence of risk factors increases the chances of getting cancer. Various gallbladder cancer risk factors have been identified

  • Gallstones: Common Among various Gallbladder Cancer Risk Factors

Among many gallbladder cancer risk factors one is gallbladder stones. More than 70% of patients with gallbladder cancer have gallstones when they’re diagnosed.The incidence of gallbladder cancer is rare as compared to gallstones as most patients with gallbladder stones will never have gallbladder cancer

  • Porcelain gallbladder

It is a condition where gallbladder wall is covered with deposits of calcium.Can occur after chronic cholecystitis or long term inflammation of the gallbladder

  • Female gender

The incidence of gallbladder cancer is more in females as compared to men.It may be correlated with increased incidence of gallstones and inflammation in the gallbladder in females

Gallbladder Cancer Risk Factors
Gallbladder Cancer Risk Factors

Obesity

It has been found that gallbladder cancer patients are obese or overweight. Gallstones are also more common in obese patients which may also explain the high risk for gallbladder cancer in these patients

  • Older age

As most cancer develop in old age same with gallbladder cancer.But incidence is increasing in young population also. In this age group it has been found that gallbladder cancer is more aggressive. Reason may be dietary and life style change

  • Ethnicity and geography

Worldwide, Incidence of gallbladder cancer is more in Central America, Pakistan and India. In India it is more common in North as compared to south

  • Choledochal cyst

These are cystic dilatation of biliary channels which are congenital

  • Gallbladder polyps

The incidence of Gallbladder cancer is more in gallbladder polyps which are more than 1cm in size, single polyp and sessile

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