CANCERS OF THE GASTROINTESTINAL SYSTEM CANCER OF THE ORAL CAVITY (STOMATITIS) Cancers of the oral cavity can occur

r in any part of the mouth or throat: are curable if discovered early. = These cancers are associated with the use of alcohol and tobacco. = Chronic irritation by a warm pipe stem or prolonged exposure to the sun and wind may predispose a person to lip cancer. = Predisposing factors for other oral cancers are exposure to tobacco (including smokeless tobacco), ingestion of alcohol, dietary deficiency, and ingestion of smoked meats. Pathophysiology: Malignancies of the oral cavity are usually squamous cell cancers. Any area of the oropharynx can be a site for malignant growth, but lips, the lateral aspects of the tongue, and the floor of the mouth are most commonly affected. Any fluid or food in the oral cavity further irritates the mucosa and causes inflammation, resulting in pain. Clinical Manifestations A number of oral cancers produce few or no symptoms in the early stages. The most frequent symptom seen in late stages is a painless sore or mass that will not heal. A typical lesion in oral cancer is painless indurated (hardened) ulcer with raised edges. Tissue from any ulcer of the oral cavity that does not heal in two weeks should be examined through biopsy. As the disease progresses, the client may complain of tenderness; difficulty in chewing, swallowing, or speaking; coughing of blood-tinged sputum; or enlarged cervical lymph nodes. Assessment and Diagnostic Findings Diagnostic evaluation consists of an oral examination as well as an assessment of the cervical lymph nodes to detect possible metastases. Biopsies are performed on suspicious lesions (those that have not healed in two weeks). High-risk areas include the buccal mucosa and gingival for people who use snuffs or smoke cigars or pipes. For those who smoke cigarettes and drink alcohol, highrisk areas include the floor of the mouth, the ventrolateral tongue, and the soft palate complex (soft palate, anterior and posterior tonsillar area, uvula, and the area behind the molar and the tongue junction). Medical Management Management varies with the nature of the lesion, the preference of the physician and client choice.

Surgical resection, radiation therapy, chemotherapy, or a combination of these therapies may be effective. Small lesions in cancer of the lip are usually excised liberally; larger lesions involving more than one-third may be more appropriately treated by radiation therapy because of superior cosmetic results. =1. The choice depends on the extent of the lesion and what is necessary to cure the client while preserving the best appearance. =2. Tumors larger than 4 cm often recur. Cancer of the tongue may be treated with radiation therapy and chemotherapy to preserve organ function and maintain quality of life. =1. A combination of radioactive interstitial implants and external beam radiation may be used. =2. If the cancer has spread to the lymph nodes, the surgeon may perform a neck dissection. =3. Surgical treatments leave a less functional tongue; surgical procedures include hemiglossectomy (surgical removal of half of the tongue) and total glossectomy (removal of the tongue). Often cancer of the oral cavity has metastasized through the extensive lymphatic channel in the neck region, requiring a neck dissection and reconstructive surgery of the oral cavity. = A common reconstructive technique involves the use of a radial forearm free flap (a thin layer of skin from the forearm along with the radial artery). Nursing Management Assess the clients nutritional status preoperatively; a dietary consultation may be necessary. Administer, if required, enteral or parenteral feedings before and after surgery to maintain adequate nutrition. If a radial graft is to be performed, carry out an Allen tests on the donor arm to ensure that the ulnar artery is patent and can provide blood flow to the hand after removal of the radial artery. 1. The Allen test is to be performed by asking the client to make a fist and then manually compressing the ulnar artery. 2. The client is then asked to open the hand into a relaxed, slightly flexed position. The palm will be pale. Pressure on the ulnar artery is released.

3. If the ulnar artery is patent, the palm will flush within about three to five seconds. Assess for patent airway postoperatively. Locate the radial pulse at the graft site and assess graft perfusion using a Doppler ultrasound device. Nursing diagnosis for a client with oral cancer may include the following: Fear related to diagnosis and long-term prognosis. Imbalanced Nutrition: Less than body requirements related to oral surgery or radical neck dissection. Disturbed Body Image related to disfiguring surgery. CANCER OF THE ESOPHAGUS Chronic irritation is a risk factor for esophageal cancer. Cancer of the esophagus has been associated with ingestion of alcohol and with the use of tobacco. Also, there seems to be an association between gastroesophageal reflux disease (GERD) and adenocarcinoma of the esophagus. People with Barretts esophagus, which is caused by chronic irritation of mucous membranes due to reflux of gastric and duodenal contents, have a higher incidence of esophageal cancer. Pathophysiology: Esophageal cancer is usually of squamous cell epidermoid type; however, the incidence of adenocarcinoma is increasing. Tumor cells may spread beneath the esophageal mucosa or directly into, and beyond the muscle layers the lymphatics. In the latter stages, obstruction of the esophagus is noted, with possible perforation into the mediastinum and erosion into the great vessels. Clinical Manifestations Clients may have an advanced ulcerated lesion of the esophagus before symptoms are manifested. Symptoms include dysphagia, initially with solid foods and eventually with liquids; a sensation of a mass in the throat; painful swallowing; substernal pain or fullness; and later regurgitation of undigested food with foul breath and hiccups. The client first becomes aware of intermittent and increasing difficulty in swallowing. = As the tumor progresses and the obstruction become more complete, even liquids cannot pass into the stomach. = Regurgitation of food and saliva occurs, hemorrhage may take place, and progressive

loss of weight and strength occurs from starvation. Later symptoms include substernal pain, persistent hiccup, respiratory difficulty, and foul breath. The delay between the onset of early symptoms and the time when the client seeks medical advice is often 12 to 18 months. anyone with swallowing difficulties should be encouraged to consult a physician immediately. Assessment and Diagnostic Findings Diagnosis is confirmed most often by esophagogastroduodenoscopy (EGD) with biopsy and brushings. Bronchoscopy is usually performed, especially in tumors of the middle and the upper third of the esophagus, to determine whether the trachea has been affected and to help determine whether the lesion can be removed. Endoscopic ultrasound or mediastinoscopy is used to determine whether the cancer has spread to the nodes and other mediastinal structures. Cancer of the lower end of the esophagus may be caused by adenocarcinoma of the stomach that extends upward into the esophagus. Medical Management Treatment goals may be directed toward cure if esophageal cancer is found at an early stage; however, if it is often found in late stages making relief of symptoms is the only reasonable goal for therapy. Treatment may include surgery, radiation, chemotherapy, or a combination of the modalities, depending on the extent of the diseases. Standard surgical management includes a total resection of the esophagus (esophagectomy) with removal of the tumor plus a wide tumor-free margin of the esophagus and the lymph nodes in the area. = The surgical approach may be through the thorax or the abdomen, depending on the location of the tumor. = When tumors occurs in the cervical or upper thoracic area, esophageal continuity may be maintained by free jejuna graft transfer, in which the tumor is removed and the area is replace with a portion of the jejunum. = A segment of the colon may be used, or the stomach can be elevated into the chest and the proximal section of the esophagus anastomosed to the stomach. Tumors of the lower thoracic esophagus are more amenable to surgery than tumors located in the esophagus, and gastrointestinal tract integrity is

maintained by anastomosing the lower esophagus to the stomach. Surgical resection of the esophagus has a relatively high mortality rate because of infection, pulmonary complications, or leakage through the anastomosis. = Postoperatively, the client will have a nasogastric tube in place that should not be manipulated. = The client is given nothing by mouth until x-ray studies confirm that the anastomosis is secure and not leaking. Preoperative radiation therapy or chemotherapy, or both, may be used; however, treatment is based on type of cell, tumor spread, and client condition. Palliative treatment may be necessary to keep the esophagus open, to assist with nutrition, and to control saliva. = Palliation may be accomplished with dilation of the esophagus, laser therapy, placement of an endoprosthesis (stent), radiation, or chemotherapy. = Treatment is individually determined since the ideal method of treating esophageal cancer has not yet been found. Nursing Management Interventions is directed toward improving the clients nutritional and physical condition in preparation for surgery , radiation therapy, or chemotherapy. If adequate food can be taken by mouth, promote weight gain based on a high-calorie and high-protein diet in liquid or in soft form. Initiate parenteral or enteral nutrition if the client is unable to eat by mouth. Monitor nutritional status throughout the treatment. Inform the client about the nature of the postoperative equipment that will be used, including the required for closed chest drainage, nasogastric suction, parenteral fluid therapy, and gastric intubation. Provide immediate postoperative care that is similar to that provided to clients undergoing thoracic surgery. Placed the client in a low Fowlers position after recovering from the effects of anesthesia. Later, position the client in a Fowlers position to assist in preventin g reflux of gastric secretions. Carefully observe the client for regurgitation and dyspnea ( a common postoperative complication is aspiration pneumonia). Monitor temperature to detect any elevation that may indicate aspiration or seepage of fluid through the operative site into the mediastinum.

Check for the graft for viability hourly for at least the first 12 hours if jejunal grafting has been performed. Assess the graft for color. Presence of pulse may be assessed using a Doppler sonography. If an endoprosthesis has been placed or an anastomosis has been performed, mark the nasogastric tube for position immediately after surgery, and notify the physician if displacement occurs. Do not attempt to reinsert a displaced nasogastric tube because damage to the anastomosis may occur. Assist physician in removing the NGT five to seven days after surgery. Perform a barium swallow to assess for any anastomotic leak before the client is allowed to eat. Encourage the client to swallow small sips of water, and, later, small amounts of pureed food once feeding begins. Discontinue parenteral fluids once the client is able to increase food intake to an adequate amount. Remind the client with endoprosthesis to chew food sufficiently to prevent obstruction. Allow the client to remain upright for at least two hours after each meal to allow the food to move through the gastrointestinal tract. Encourage the client with poor appetite to eat by involving the family to prepare home-cooked favorite foods. Administer antacids to relieve gastric distress as ordered. Provide liquid supplements, which are more easily tolerated by clients undergoing radiation and experiencing esophagitis. During discharge planning, instruct the family about promotion of adequate nutrition, what observations to make, measures to take if complications occur, how to keep the client comfortable, and how to obtain needed physical and emotional support. GASTRIC CANCER Etiology and Risks Factors of the Disease = Due to diet high in smoked foods. = Lack of fruits and vegetables in the diet. = Chronic stomach inflammation. = Pernicious anemia (Vit. B12 deficiency) = Achlorhydria (absence of hydrochloric acid. = Gastric ulcers. = Due to Helicobacter pylori bacteria. Pathophysiology: Most gastric cancers are adenocarcinomas; they can occur anywhere in the stomach. The tumor infiltrates the surrounding mucosa, penetrating the wall of the stomach and adjacent organs and stomach.

The liver, pancreas, esophagus, and duodenum are often already affected at the time of diagnosis. Metastasis through lymph to the peritoneal cavity occurs later in the disease. Clinical Manifestations Early signs may be absent, leading to indigestion. Anorexia Dyspepsia Weight loss Abdominal pain Constipation Assessment and Diagnostic Findings The physical examination is usually not helpful in detecting the cancer because most early gastric tumors are not palpable. Advance gastric cancer may be palpable as a mass. Ascites and hepatomegaly (enlarged liver) may be apparent if the cancer cells have metastasized to the liver. Palpable nodules around the umbilicus, called Sister Mary Josephs nodules are a sign of a GI malignancy, usually a gastric cancer. Esophagogastroduodenoscopy for biopsy and cytologic washings is the diagnostic study of choice, and a barium x-ray examination of the upper GI tract may also be performed. Endoscopic ultrasound is an important tool to assess tumor depth and any lymph node involvement. Computed tomography completes the diagnostic studies, particularly to assess for surgical respectability of the tumor before surgery is scheduled. CT scan of the chest, abdomen, and pelvis is valuable in staging gastric cancer. Treatment: Radical surgery. Subtotal gastrectomy Total gastrectomy Chemotherapy COLON CANCER Etiology and Risk Factors: = Family history of colon cancer. = Chronic inflammatory bowel disease. = Polyps = Low-fiber diet. = The incidence increases with age (the incidence is highest for people older than 85 years of age). = The exact cause of colon cancer is still unknown but risk factors have been identified. = Increasing age

= Family history of colon cancer or polyps = Previous colon cancer or polyps. = High-fat, high-protein (with high intake of beef), low-fiber diet. Distribution of Cancer Sites Throughout the Colon Ascending colon = 22 % Transverse colon = 11 % Descending colon = 6 % Sigmoid colon = 33 % Rectum = 27 % Pathophysiology: Cancer of the colon are predominantly adenocarcinoma, arising from the epithelial lining of the intestine. It may start as a benign polyp but may become malignant, invade and destroy normal tissue, and extend into surrounding structures. Cancer cells may break away from the primary tumor and spread to other parts of the body, most often to the liver. Clinical Manifestations Change in bowel habits. Passage of blood in stools. Unexplained anemia, anorexia, weight loss, and fatigue. Right sided: abdominal pain, melena. Left sided: abdominal pain, cramping, narrowing stools, constipation, distention. TREATMENT: Chemotherapy radiation therapy Segmental resection with anastomosis Abdominoperitoneal resection with permanent sigmoid colostomy (removal of the tumor and a portion of the sigmoid and all of the rectum and anal sphincter). Temporary colostomy. Permanent colostomy or ileostomy.