FACULTY OF NURSING

SRI RAMACHANDRA UNIVERSITY

DEPARTMENT OF MEDICAL
SURGICAL NURSING
13th CONTINUING NURSING
EDUCATION
THEME DIGESTIVE
DISEQUILIBRIUM : NURSES CONCERN

Presenter
Mrs.M.Malarvizhi,
Lecturer,
Faculty of Nursing, SRU
25.07.2014

Outline

Terminologies

Cancer, its causes and types

Anatomy of the gastrointestinal tract and site of

malignancy

Gastrointestinal malignancy

Meaning

Causes and risk factors

Cancer progression

Staging

Clinical manifestations

Diagnostic evaluation

Treatment / Prognosis

Nursing care of patient with gastrointestinal

malignancies

Preventive and Rehabilitative measures

References

TERMINOLOGIES
CAUSES OF CANCER

TYPES OF CANCER

Malignant conditions of the

gastrointestinal tract (GI tract) and
accessory organs of digestion.

 Spread by direct extension to

involve
entire bowel circumference and
adjacent organs.
Metastasis to regional lymph nodes
via
lymphatic and circulatory systems to
liver, lungs, brain, bones, and
kidneys.

CAUSES AND RISK

FACTORS FOR
GASTROINTESTINA
L CANCER

ESOPHAGEAL
CANCER
`
Incidence:

3-5 males : 1 female.

Site:
30%

Upper third: 20% ; Middle third:

Lower third: 50%

Causes:
asbestos

Barretts esophagus, exposure to

Pathophysiology:

STAGING OF
OESOPHAGEAL
CANCER
ESOPHAGEAL
CANCER contd
Types:

Adenocarcinoma (70 %)
Squamous cell carcinoma

C/M:

Substernal / epigastric

Complications:

Haemorrhage

Esophageal perforation,
Esophageal obstruction,
Metastasis to liver and lungs
Surgery:

Esophagectomy
Esophagogastrostomy
Esophagoenterostomy

GASTRIC CANCER
Type

Adenocarcinoma (94%),

Lymphoma (4%), GIST,

Sarcoma
Causes:

Pernicious anaemia,
Blood groupA,
Family history, Tobacco
past Sx/of Gastrectomy

Gross appearance:

Polypoid, Fungating,

Ulcerative
C/M:

Decreased food intake,

Abdominal pain, Nausea,
Vomiting and bloating,
GI bleeding, Dyspepsia,
Ascites ( poor prognosis)

GASTRIC CANCER
contd
Surgery: Surgical Resection
Radical subtotal gastrectomy
Total gastrectomy with esophago
jejunostomy

PANCREATIC
CANCER
Types: Endocrine or non endocrine tumors.
Ductal adenocarcinoma
Location : 60% head, 25% body, 15% tail
Risk factors :Chronic pancreatitis, diabetes

C/M: severe pain in the upper abdomen,

jaundice.

STAGING OF
PANCREATIC
CARCINOMA
PANCREATIC
CANCER contd.

Whipple`s
procedure

LIVER CANCER
Types:
Hepatocellular carcinoma
Hepatoma
Risk factors:
C

Hepatitis B or
Cirrhosis

C/M:
pruritis, ascites
Treatment:

Jaundice,

Surgical resection,

Embolisation ,
Ablation
Liver
transplant
Complications:
Gastrointestinal
bleeding
Cachexy
Portal
hypertension
Liver failure
Metastasis
Rupture of tumor

STAGING OF
HEPATOCELLULAR
CARCINOMA (INCLUDING
INTRAHEPATIC BILE DUCTS)

Transcatheter
arterial
chemoembolizatio
n (TACE)

Other techniques
Radiofrequency ablation (RFA)
High intensity focused ultrasound
(HIFU)

 Chemotherapy (antiestrogen +
tamoxifen)

Cryosurgery
GALL BLADDER
CANCER
Types:
Adenocarcinomas
Risk factors: Gallstones

C/M:

Weight loss,
Jaundice
Right hypochondric pain
Surgery: Cholecystectomy with
part of
liver and lymph node
dissection.

COLORECTAL
CANCER
Risk factors :
Diets low in vegetable fibre and high in fat
Hereditary nonpolyposis
Familial adenomatous polyposis.

WHO Classification:

Adenocarcinoma in situ / severe dysplasia

Adenocarcinoma

Mucinous (colloid) adenocarcinoma (>50%

mucinous)

Signet ring cell carcinoma (>50% signet ring

cells)

Squamous cell (epidermoid) carcinoma

Adenosquamous carcinoma

Small-cell (oat cell) carcinoma

Medullary carcinoma

Undifferentiated Carcinoma

ANATOMIC
LOCATION OF CRC

Cecum

Ascending colon

Transverse colon

12 %

Descending colon

7 %

Sigmoid colon

Rectosigmoid junct.

Rectum

14 %
10 %

25 %
9 %

23 %

MODIFIED DUKES' STAGING

CLASSIFICATION OF
COLORECTAL CANCER.

COLORECTAL
CANCER contd

STAGING
Rectal Surgery:

Local resection for those with stage I rectal cancer. Cutting

through all layers of the rectum to remove invasive cancers
and some surrounding normal rectal tissue.

Many stage I and most stage II and III are removed by either
low anterior (LA) resection or abdominoperineal (AP)
resection

LA resection-for cancers near upper part of rectum, colon is

reattached to the lower part of the rectum and waste
elimination is normal

AP resection-for cancers in the lower part of rectum, the

cancerous tissue as well as the anus is and a permanent
colostomy is necessary

Photocoagulation (heating the rectal tumor with a laser beam

aimed through the anus) is an option for relieving or
preventing rectal blockage in patients with stage IV cancer

Colostomy

Sigmoid colostomy
resection

: Used with A-P

Double-barrel colostomy : 2 stomas:

proximal for feces diversion; distal is
mucous fistula
Transverse loop colostomy: Emergency
procedure; loop suspended over a
bridge; temporary
Hartman procedure:
Distal portion is
left in place and oversewn; only
proximal
colostomy is brought to abdomen as
stoma; temporary;
colon reconnected at later time
when patient is
ready for surgical repair

ANAL CANCER
Pectinate line (dentate line),
about 12 cm from the anal
verge (where the anal mucosa
of the anal canal becomes
skin).
* above - adenocarcinomas

* below - squamous cell

carcinomas
Risk factors:
ulcerative colitis , sexually
transmissible infections HPV
and HIV.
Typical feature:
constipation or tenesmus, or may
be felt
as a palpable mass.

GASTROINTESTINA
L CARCINOID
TUMOR
Rare, slow-growing form of

cancer that affects certain cells

in the lining of the stomach
and intestines.
Usually occurs in the appendix,
small intestine, or rectum.
Increases risk of cancers
affecting the other parts of the
digestive system.

Staging-American Joint
Committee on Cancer
system (AJCC/TNM)
Staging is an indicator of survival

TNM Classification

CLINICAL
FEATURES OF
GASTROINTESTINA
L CANCER
Symptoms of gastrointestinal cancer vary,
depending on the type of cancer

dysphagia,

 abdominal pain, tenderness, or discomfort

change in bowel habits, such as frequency
or consistency or shape

rectal bleeding or blood in stool

bloating
loss of appetite
nausea/vomiting
unintentional weight loss
fatigue

Diagnostic evaluation
of Gastrointestinal
Cancer

History and Physical examination

Digital rectal examination

Complete blood count

Urinalysis

Stool examination

Sigmoidoscopy / Colonoscopy

Liver enzymes

TREATMENT OF
GASTROINTESTINA
L CANCER
TREATMENTRADIATION
THERAPY
Treatment with high energy rays (such as x-rays) to
kill or shrink cancer cells
May be external radiation (from outside of the body)
or radioactive materials placed directly in the
tumor (internal or implant radiation)

Adjuvant treatment (after surgery)-radiation is given

to kill small areas of the cancer that are hard to
see
Neoadjuvant treatment (before surgery)-radiation
shrinks the tumor if the size or location of the
tumor makes surgery difficult

TREATMENTRADIATION
THERAPY contd
External Radiation:

treatments given 5 days a week for

several weeks

last a few minutes and is similar to

having an x-ray taken
Internal Radiation:

 small pellets, or seeds, of radioactive

material are placed next to or directly into
the cancer

used in treatment of people with

especially the sick or elderly that would
not be able to withstand surgery

TREATMENTCHEMOTHERAPY
Chemotherapy:

useful for metastasized cancers

chemo following surgery increases the survival

rate for some stages

chemo helps relieve symptoms of advanced

cancer

TREATMENTCHEMOTHERAPY
contd
TREATMENTIMMUNOTHERAPY
Monoclonal antibodies in a laboratory
that are designed to recognize and bind to
the antigen of a specific cancer cell.

RIT, the monoclonal antibody is paired

with a radioactive material. When
injected into the patients bloodstream,
the antibody travels to and binds to the
cancer cells

Allowing a high dose of radiation to be

delivered directly to the tumor.

NEW HOPE IN
CANCER
TREATMENTS
Remove less surrounding

tissue during surgery

Combine surgery with
radiation or chemotherapy
Immunotherapy
Cancer-fighting vaccines
Gene therapy
Neoadjuvant chemotherapy
Stem cell research

STAGE AND
PROGNOSIS
Stage
(%)

5-year Survival

0,1

Tis,T1;No;Mo

> 90

T2;No;Mo

80-85

II

T3-4;No;Mo

70-75

III

T2;N1-3;Mo

70-75

III

T3;N1-3;Mo

50-65

III

T4;N1-2;Mo

25-45

IV

M1

<3

NURSING
DIAGNOSES

Pain

Imbalanced Nutrition: Less than body

requirements(may include enteral tube
feeding or parenteral nutrition in
hospital and home)

Ineffective coping related to cancer

diagnosis and treatment

Anticipatory Grieving(dealing with

cancer diagnosis)

Alteration in Body Image

Risk for Sexual Dysfunction

NURSING
INTERVENTIONS
Meticulous oral care
Milk of magnesia to remove crust
formation
IV fluid replacement
Parenteral nutrition
Gastrostomy feeding
Positioning
Incentive spirometry
Ambulation

 Side effects of chemotherapy

-management

NURSING
INTERVENTIONS
contd
Diet

Decrease amount of fat, refined sugar, red meat;

increase amount of fiber; diet high in fruits and
vegetables, whole grains, legumes

Colostomy: Avoid odour producing , gas forming,

diarrhea causing, potential obstruction

Screening recommendations

Seek medical attention for bleeding and warning

signs of cancer

Home Care

Referral for home care

Referral to support groups for cancer or ostomy

Referral to hospice as needed for advanced

disease

NURSING
INTERVENTIONS
contd
Post-op care

Pain
NG tube
Wound management

 Stoma
Should be pink and moist
Dark red or black indicates ischemic
necrosis
Look for excessive bleeding
Observe for possible separation of
suture securing stoma to abdominal
wall

Evaluate stool after 2-4 days post op

Ascending stoma (right side)
Liquid stool
Transverse stoma
Pasty
Descending stoma
Normal, solid stool

CANCERS SEVEN
WARNING
SIGNALS
Preventing
cancer through
Diet and
Lifestyle
CANCER
REHABILITATION
FOLLOW -UP

Relapse
Survival
Toxicity
Quality of life
CANCER
SURVIVORS

Cancer support groups

Cancer information workshops
Low-cost medical consultation
Increased government funding

to seek cures

REFERENCES

Yamada T, Alpers DH, et al. (2009). Textbook of

gastroenterology (5th ed.). Chichester, West Sussex: Blackwell
Pub. pp. 603, 1028. ISBN 978-1-4051-6911-0.
OCLC 404100761.
Bjelakovic, G; Nikolova, D; Simonetti, RG; Gluud, C (Jul 16,
2008). "Antioxidant supplements for preventing gastrointestinal
cancers.". The Cochrane database of systematic reviews (3):
CD004183. doi:10.1002/14651858.CD004183.pub3.
PMID 18677777. Cite uses deprecated parameters
"Death and DALY estimates for 2004 by cause for WHO
Member States (Persons, all ages)". WHO. Retrieved 12 October
2013.
Yang, S; Wu, S; Huang, Y; Shao, Y; Chen, XY; Xian, L; Zheng, J;
Wen, Y; Chen, X; Li, H; Yang, C (Dec 12, 2012). "Screening for
oesophageal cancer.". The Cochrane database of systematic
reviews 12: CD007883. doi:10.1002/14651858.CD007883.pub2.
PMID 23235651. Cite uses deprecated parameters
Bennett, C; Wang, Y; Pan, T (Oct 7, 2009). "Endoscopic mucosal
resection for early gastric cancer.". The Cochrane database of
systematic reviews (4): CD004276.
doi:10.1002/14651858.CD004276.pub3. PMID 19821324. Cite
uses deprecated parameters

11.

^Moss, AC; Morris, E; Mac Mathuna, P (Apr 19, 2006).

"Palliative biliary stents for obstructing pancreatic carcinoma.".
The Cochrane database of systematic reviews (2): CD004200.
doi:10.1002/14651858.CD004200.pub4. PMID 16625598. Cite
uses deprecated parameters .
Davidson's principles and practice of medicine. (21st ed. ed.).
Edinburgh: Churchill Livingstone/Elsevier. 2010. ISBN 978-07020-3085-7. OCLC 455157186.
Bruce G. Wolff et al., ed. (2007). The ASCRS textbook of colon
and rectal surgery. New York: Springer. p. 1. ISBN 0-387-248463.
Harrison's principles of internal medicine. (17th ed. ed.). New
York [etc.]: McGraw-Hill Medical. 2008. ISBN 978-0-07147692-8. OCLC 237889182.
"Gastrointestinal Carcinoid Tumor". National Cancer Institute at
the National Institutes of Health. Retrieved 15 October 2013.
www.cancer.gov, www.cancer.org, www.cdc.gov,
www.nccn.org