2005: PBL- Oesophageal cancer

What are the common symptoms associated with stage 2 oesophageal cancer?

Difficulty Swallowing (Dysphagia), Unintentional Weight Loss, Painful Swallowing (Odynophagia), Reflux and Indigestion, Regurgitation, Chest pain or discomfort, some fatigue.

What is not a common complication associated with stage 2 oesophageal cancer?

Cancer creates an abnormal connection (fistula) between the esophagus and the windpipe (trachea) or bronchi, often causing severe coughing, choking, or pneumonia.

How does oesophageal cancer impact a patient's ability to eat and swallow what is one key reason?

Difficulty Swallowing (Dysphagia)

Which symptom involves difficulty in swallowing?

Dysphagia

Oesophageal cancer impairs swallowing by:

Narrowing and obstructing the oesophageal lumen

Adenocarcinoma oesophageal cancer is

a common, often aggressive form of oesophageal cancer arising in the glandular cells of the lower oesophagus, frequently linked to chronic acid reflux (GERD) and Barrett’s oesophagus.

Squamous cell carcinoma oesophageal cancer is

an aggressive cancer originating in the thin, flat cells lining the upper and middle oesophagus.

Small Cell Carcinoma oesophageal cancer is

highly aggressive neuroendocrine tumor representing it behaves aggressively with early metastasis, often resulting in a poor prognosis.

Melanoma oesophageal cancer is

highly aggressive cancer arising from melanocytes in the oesophageal mucosa it typically affects patients 60+, often in the lower/middle oesophagus, and is characterized by late diagnosis, high metastasis, and a poor prognosis.

Odynophagia

(painful swallowing) is a significant symptom of It is a significant symptom of advanced oesophagal or throat cancer, resulting from tumours obstructing or ulcerating the oesophagus.

IDDSI framework is known as

International Dysphagia Diet Standardisation Initiative framework

Why is enteral nutrition often necessary for patients with oesophageal cancer?

the disease and its treatments frequently make normal eating impossible or dangerous.

Why is this the case ‘Enteral nutrition is preferred over parenteral nutrition where possible, provided the gastrointestinal tract remains functional for patients with oesophageal cancer.’?

enteral feeding preserves gut integrity, maintains the intestinal mucosal barrier, reduces the risk of infection associated with central venous access, and is more physiologically appropriate.

Delivery routes include a ________________ for short-term use or a ________________for longer-term nutritional support, particularly in patients undergoing extended treatment or those with significant swallowing impairment.

Nasogastric (NG) tube. Percutaneous endoscopic gastrostomy (PEG).

Nasogastric (NGT/NG) Tube:

Inserted transnasally into the stomach, typically at the bedside, with position confirmed by pH ≤5.5. Difficult placements may require endoscopic or radiological help. Before administering water, feed, or medications, the tube's position must be verified by pH or X-ray.

Wide bore NGT (e.g. Ryles) tube:

Enteral tube passed trans-nasally into the stomach and gastric placement confirmed with X-ray or pH ≤5.5. Often sited at time of surgery but can also be placed at the bedside.

Nasojejunal (NJT/NJ) Tube:

Inserted through the nose, passing through the stomach into the jejunum (small intestine). Used when the stomach cannot be used, such as with severe reflux or gastroparesis. Used when gastric feeding is not tolerated or safe.

Stomagastric feeding tube:

Feeding tube is placed through a laryngectomy stoma into the stomach via the oesophagus, usually involving a puncture in the trachea's back wall during head and neck surgery to prepare for a voice prosthesis.

Percutaneous Endoscopic Gastrostomy (PEG) Tube:

A __ tube is placed during endoscopy via the pull-through technique. A guidewire is inserted into the stomach and pulled through the mouth with an endoscope. The feeding tube is then attached to the guidewire and secured by a bumper.

Orogastric feeding tube:

A tube is inserted via the mouth rather than the nose. Inserted transnasally into the stomach, typically at the bedside, with position confirmed by pH ≤5.5. Difficult placements may require endoscopic or radiological help. Before administering water, feed, or medications, the tube's position must be verified by pH or X-ray.

Radiologically Inserted Gastrostomy (RIG) Tube:

A tube is placed under x-ray in interventional radiology. A nasogastric tube inflates the stomach, and gastropexy secures the stomach to the abdominal wall, with a stoma created for tube insertion. These tubes typically use 5-20 ml of water, along with low-profile devices.

Percutaneous endoscopic gastrostomy Tube (G-Tube):

PEG is inserted using a pull-through technique, a guidewire is inserted into the stomach and pulled out through the mouth, allowing a feeding tube to be attached and secured with a bumper.

Per-oral image-guided gastrostomy feeding tube:

A pig undergoes gastrostomy placement in interventional radiology using X-ray guidance. A nasogastric tube inflates the stomach for better visualisation. A needle punctures the stomach, a guide wire is threaded through the oesophagus, and the gastrostomy is pulled through and secured at the stoma with a bumper.

How do you decide which type of feeding tube is appropriate for a patient?

The dietitian will assess nutritional status and clinical condition, tailoring feed prescriptions to individual nutritional needs and intervention goals. A variety of feeds are available, typically providing 1-2 kcal/ml, with or without fiber.

What is not an appropriate way dietitians can manage symptoms like nausea, diarrhoea, or constipation in these patients with Oesophageal cancer?

Consumption of high-fibre foods (like raw vegetables, tough meats, or husks) helps to move food in the oesophagus.

What are the key indicators to monitor in patients receiving enteral nutrition?

Food chart (if appropriate), Fluid balance charts, Urine frequency and colour, Weight/BMI, Temperature / pulse / respiration, Bowels, Capillary blood glucose, Medication, Nausea and vomiting, Gastric residual volumes, Feeding tube position, Feeding tube insertion site, Tube integrity, Gastrostomy rotation, Gastrostomy progression, Balloon water volume (balloon retained tubes), General clinical condition of patient, Oral health.

What are the key indicators to be monitored daily in patients receiving enteral nutrition?

Food chart (if appropriate), Fluid balance charts ( in acute setting), Temperature / pulse / respiration (when in acute unit), Bowels, Capillary blood glucose, Medication, Nausea and vomiting, Gastric residual volumes, Feeding tube position, Feeding tube insertion site, Tube integrity, Gastrostomy rotation, General clinical condition of patient, Oral health.

What are the key indicators to be monitored weekly in patients receiving enteral nutrition?

Gastrostomy progression, Balloon water volume (balloon retained tubes), Weight/BMI.

What is false about how you adjust the feeding regimen based on a patient's tolerance and nutritional needs?

People who have eaten little or nothing for more than 5 days should have nutrition support introduced at no more than 50% of requirements for 4 days, before increasing feed rates to meet full needs if clinical and biochemical monitoring reveals no refeeding problems. Full requirements for electrolytes and minerals should be met from the outset of feeding. 

What strategies can not dietitians use to support the mental health of their patients?

Intuited Eating: Teaching techniques about "what" you eat, but "how" you eat.

What are not the nutritional considerations for oesophageal cancer patients after surgery or other treatments short term?

Lying Down After Eating: Lie flat immediately after eating; for 45–60 minutes is necessary to prevent reflux.

What are not the nutritional considerations for oesophageal cancer patients after surgery or other treatments long term?

High-Fiber Foods: High-fiber, bulky foods (like wholemeal bread, raw vegetables, bran) are recommended immediately as they can cause fullness and energy.

How can dietitians not help patients transition from enteral nutrition to oral intake?

Address Psychosocial Barriers: Manage the psychological aspects of the transition, such as fear of eating, fear of choking, or lack of appetite, which are significant barriers to successful tube weaning.

Why is it not important for dietitians to work closely with other healthcare professionals in managing oesophageal cancer?

Optimising Treatment Working With Other Health Care Professionals: Managing nutrition does not require input from surgeons or oncologists

What is false about how can dietitians contribute to the overall treatment plan for oesophageal cancer patients?

Weight gain and not addresing the physical texture of food.

What is false about how can dietitians contribute to the overall treatment plan for oesophageal cancer patients?

Intervene once a patient has reached a state of severe clinical cachexia (wasting).

What is false about how can dietitians contribute to the overall treatment plan for oesophageal cancer patients?

Specific 'cancer-killing' diets (e.g., alkaline or keto) to replace chemotherapy.

How can dietitians contribute to the overall treatment plan for oesophageal cancer patients? What is involved in ‘Early Nutritional Assessment and Planning’

Malnutrition Screening: Dietitians screen for malnutrition at diagnosis and throughout treatment to identify high-risk patients early. - Use MUST tool. Tailored Interventions: They create personalized nutritional therapy plans, adjusting for dysphagia (swallowing difficulties), weight loss, and reduced appetite.- Texture Modification, ONS, Tube Feeding. Monitoring Pre-treatment: Dietitians help manage nutritional status during neoadjuvant (pre-surgery) therapy to improve weight maintenance, reduce surgical complications, and ensure patients finish their chemotherapy/radiotherapy.

How can dietitians contribute to the overall treatment plan for oesophageal cancer patients? What is involved in ‘Management of Eating Difficulties and Side Effects’

Texture Modification: They provide advice on food consistency (e.g., soft, puréed, or liquid diets) to make swallowing safer and easier. Symptom Management: Dietitians offer strategies to manage treatment-related side effects such as nausea, dry mouth, and mouth sores. Oral Nutrition Support: They suggest high-calorie, high-protein food fortification to maximise nutritional intake from small amounts of food.

How can dietitians contribute to the overall treatment plan for oesophageal cancer patients? What is involved in ‘Enteral and Parenteral Nutrition Support ’

Tube Feeding Management: When patients cannot eat enough, dietitians recommend and manage enteral nutrition (nasogastric or feeding tubes). Home Enteral Feeding Support: They coordinate with home care teams to ensure patients have necessary supplies and support, allowing them to continue feeding at home. Transitioning Feeding: They create plans to help patients move from tube feeding back to oral intake as they recover.

How can dietitians contribute to the overall treatment plan for oesophageal cancer patients? What is involved in ‘Perioperative Support (Pre- and Post-Surgery)’

Prehabilitation: Dietitians optimise nutritional status before surgery (e.g., 7-10 days pre-op) to enhance healing, reduce infections, and speed recovery. Post-operative Management: Following surgery, they advise on introducing liquids and food, transitioning from a soft diet back to more solid foods. Managing Post-op Complications: They assist with the management of issues like dumping syndrome, reflux, and ongoing swallow difficulties.

How can dietitians contribute to the overall treatment plan for oesophageal cancer patients? What is involved in ‘Education and Counselling ’

Empowering Patients: Dietitians teach patients and caregivers how to adjust their diet to "a new normal" and manage long-term dietary changes. Weight Management: They monitor weight weekly, encouraging the maintenance of a healthy weight to prevent treatment delays or dose reductions.