Gastrointestinal Cancers and Disorders Lecture Review

Oral Cancer: Clinical Manifestations and Risk Factors

  • Risk Factors for Oral Cancer:

    • Dietary intake of "junk food" and highly salted foods.

    • Poor dental hygiene.

    • Prolonged exposure to certain toxins or environmental factors.

    • Tobacco and alcohol consumption (primary prevention involves avoiding these).

  • Specific Clinical Manifestations:

    • Leukoplakia: White patches or lesions on the mucous membranes of the oral cavity. The term "leuko" means white.

    • Erythroplakia: Red patches or lesions. The term "erythro" means red. These are often considered precancerous or early cancerous changes.

    • Limitation in Hormones: While hormone changes can occur, they are generally considered non-specific to oral cancer diagnosis.

  • Non-Specific and Advanced Symptoms:

    • Many symptoms are non-specific, meaning they appear in various other disease conditions. These include:

      • Persistent sore throat.

      • Voice changes (this occurs as the cancer spreads to the vocal cords or nearby nerve structures).

      • Ulcerations that do not heal like a normal ulcer.

  • Diagnostic Procedures:

    • Toluidine Blue Dye Test: The patient is asked to rinse their mouth with a specific dye. A bluish color change indicates areas of potential concern. This is not a definite diagnosis but suggests the need for further investigation.

    • Biopsy: This is the only method for a confirmed, definite diagnosis.

    • Imaging:

      • CT Scan and MRI: Used to see more clearly if the cancer has spread to other parts of the body.

      • PET Scan: Uses glucose reactants to identify areas of high metabolic activity, indicating where the tumor has spread.

Nursing Assessment and Interventions for Oral Cancer

  • Surgical Options:

    • Partial Mandiblectomy: Removal of part of the mandible (jawbone) along with the tumor.

    • Glossectomy: Surgical removal of the tongue (the term "gloss" refers to the tongue).

  • Nursing Priorities and Interventions:

    • Airway Management: This is the primary priority due to proximity to the respiratory tract and potential for obstruction.

    • NPO Status: Patients are often Nothing Per Oral (NPO) due to the risk of aspiration and presence of sutures/surgical trauma inside the mouth.

    • Communication: This is a vital nursing intervention. Because patients cannot talk post-tongue removal, communication techniques must be taught before the surgery. The student must prioritize communication even over nutrition initially to facilitate assessments and comfort.

    • Nutrition:

      • Many patients have loss of appetite even before surgery.

      • PEG (Percutaneous Endoscopic Gastrostomy) Tube: If the stomach is functional, a PEG tube is ideal for providing nutrition while bypassing the oral cavity.

      • Tracheostomy Considerations: If the patient has a tracheostomy tube, they can sometimes eat if the balloon is inflated to prevent aspiration, though they may not tolerate it well initially.

    • Oral Care: Very important to prevent infection. Use a sponge or soft toothbrush for each unit/cleaning to avoid trauma to surgical sites.

    • Pain Management: Pain relief and comfort must be addressed early in the care plan.

Esophageal Cancer: Pathophysiology and Manifestations

  • Etiology and Risk Factors:

    • Chronic Regurgitation: Constant irritation of the esophageal mucosa by gastric acid leading to inflammation.

    • Barrett's Esophagus: A condition where the cellular lining of the esophagus changes due to chronic irritation (often from GERD), which can lead to cancer.

    • Achalasia: A condition where the lower esophageal sphincter fails to relax, causing food to stick and irritating the mucosa.

  • Clinical Manifestations:

    • Progressive Dysphagia: Difficulty swallowing that worsens over time. A common timeline presented is seeing changes over years; first, the patient cannot eat solids/meat, and eventually, they cannot even drink water.

    • Weight Loss and Regurgitation: Common signs as the tumor sits and obstructs the esophagus.

  • Surgical and Palliative Treatment:

    • Esophagectomy: The cancerous part of the esophagus is removed. The doctor must pull the remainder of the stomach up into the chest to attach it to the remaining esophageal stump.

    • Chemotherapy and Radiation: Often used before surgery to shrink the tumor. If the cancer has metastasized (spread to liver, lungs, or brain), surgery may not be beneficial, and these are used as palliative comfort measures to reduce the size of the tumor so the patient can swallow better before they die.

    • Endoscopic Procedures:

      • Ablation: Burning or scraping the tumor to reduce its size and reduce the narrowing of the esophagus.

      • Dilation: Procedures to dilate the esophagus so the patient can have some nutritional intake.

Post-Operative Nursing Care for Esophageal Surgery

  • Critical Monitoring:

    • Anastomosis Leaks: This is a major complication where the surgical connection (anastomosis) leaks. Signs include abdominal pain, fever, and an elevated White Blood Cell (WBC) count.

    • Respiratory Status: Patients are at high risk for aspiration and pulmonary complications.

    • DVT Prophylaxis: Use of compression stockings or medications to prevent deep vein thrombosis.

  • Nutritional Support:

    • Parenteral Fluids: IV fluids used initially.

    • Jejunostomy (J-Tube): A tube placed in the jejunum because the most nutrients are absorbed there. This must be taken care of cautiously to prevent clogging, which would require surgical replacement.

    • Swallow Study: A speech therapist must perform a swallow evaluation before the patient begins taking sips of water or food to ensure safety.

  • Pain Management:

    • Multimodal Pain Management: Using multiple types of medication (e.g., Tylenol via IV or other routes) to reduce the total amount of opioids/drugs needed. This helps the patient deep breathe, cough, and move faster to prevent GI and respiratory stagnation.

Stomach (Gastric) Cancer

  • Characteristics:

    • Very fast-growing cancer that often spreads to distant organs (liver, pancreas, gallbladder) before symptoms become evident.

    • Often diagnosed very late because symptoms are mistaken for common issues like indigestion.

  • Risk Factors:

    • Diet: High intake of smoked or preserved foods.

    • Atrophic Gastritis: Inflammation that affects the glands inside the stomach.

    • Polyps: Proliferating folds or growths that can become cancerous.

  • Late-Stage Manifestations:

    • Unexplained weight loss and lack of appetite.

    • Anemia and Fatigue: Resulting from cancer cells affecting the body's blood production.

    • Ascites: Distended abdomen due to fluid buildup, often signifying the cancer has spread to the liver.

  • Nursing Care Post-Gastric Surgery:

    • Nasogastric (NG) Tube: Used for decompression of the stomach.

    • Crucial Rule: Do NOT touch, move, or flush the NG tube after gastric surgery unless specifically instructed by the surgeon. The tube is often placed near delicate sutures (anastomosis) and moving it can destroy the surgical site.

    • Monitor Output: Watch for changes in the contents coming from the NG tube over time.

Colon Cancer and Bowel Obstructions

  • Risk Factors:

    • Genetics: Family history is significant.

    • Autoimmune/Inflammatory Diseases: Chronic conditions like Ulcerative Colitis and Crohn’s disease are major risk factors.

  • Clinical Manifestations:

    • Signs of bowel obstruction: Nausea, vomiting, abdominal distension, and constipation (unable to pass gas or stool for weeks).

    • Colicky abdominal pain.

    • Blood in your stool (though this can also be from hemorrhoids and is not specific).

  • Diagnosis and Screening:

    • Colonoscopy: The gold standard for definitive diagnosis via tissue sample (biopsy). Recommended every 1010 years for those at risk.

    • Fecal Occult Blood Test (FOBT): Checking stool for hidden blood.

    • Carcinoembryonic Antigen (CEA): A tumor marker (special protein) checked in the blood to see how vigorous the disease is or if it is advancing.

  • Surgical Procedures:

    • Low Anterior Resection (LAR): Used for cancers of the rectum where part of the rectum is removed and the remainder is sutured.

    • Permanent Ostomy: If the tumor is too advanced or involves the anus/rectum completely, a permanent ostomy is required.

  • Nursing for Ostomy Patients:

    • Education on the device and skin care is vital.

    • Monitor for drainage; a significant reduction in drainage with abdominal distension may indicate an obstruction.

    • Dietary teaching: Avoid foods that cause excessive gas.

    • Sitz Bath: Use of warm water for incisions in the rectal area to promote cleaning and healing.

Gastrointestinal (GI) Bleeding and Emergency Management

  • Types of Bleeding:

    • Upper GI Bleed: Often presents as Melena (black, tarry stool) because the blood has time to sit with hydrochloric acid. Can also involve hematemesis (throwing up blood).

    • Lower GI Bleed: Often presents as bright red blood (hematochezia), which can sometimes be confused with hemorrhoids.

  • Esophageal Varices:

    • Often caused by Portal Hypertension (the "Costco Truck" metaphor: The liver cannot take the blood from the GI system/portal vein, so the pressure forces blood into tiny, fragile vessels in the stomach and esophagus).

    • If these vessels (varices) pop, it is a disaster and a life-threatening emergency due to massive blood loss.

  • Emergency Interventions for Shock:

    • Signs of Shock: Tachycardia (high heart rate), hypotension (low blood pressure), pale skin ("paper white"), and decreased level of consciousness/lethargy.

    • Priority Actions:

      1. Check for a pulse/breathing.

      2. Insert a large-bore IV catheter immediately.

      3. Start IV fluid resuscitation to bring blood pressure up and maintain organ perfusion (preventing brain/kidney death).

      4. Prepare for blood transfusion (Red blood cells, Platelets, and Plasma).

    • Gastric Lavage: A special tube is inserted to rinse the stomach of blood so that an endoscopy can be performed once the patient is stabilized.

Gastritis and Stress Ulcers

  • Etiology:

    • Acute vs. Chronic: Can be localized or diffuse over the whole stomach.

    • Drug-Induced: Long-term use of Aspirin or NSAIDs (Indomethacin).

    • H. pylori: A bacterial infection. Testing includes serum, stool antigen, and breath tests.

  • Stress-Related Ulcers:

    • Curling’s Ulcer: Gastritis/ulcers resulting from extensive burns due to the inflammatory response and cell destruction.

    • Cushing’s Ulcer: Gastritis/ulcers resulting from head trauma or brain surgery.

  • Nursing Management:

    • NPO Status: To rest the GI tract.

    • Reintroducing Food: Start with ice chips, then clear liquids, then full liquids, then soft diet (gradual progression).

    • Vitamin B12B_{12} Injections: Patients with chronic gastritis may have a lifelong deficiency and need supplementation.

    • Medications: Antacids, H2 receptor blockers (generic and trade names like famotidine/Pepcid), and Proton Pump Inhibitors (PPIs).

Questions & Discussion

  • Question: Do I need to know how an endoscopy is performed in detail?

    • Response: No, we are not doctors. The nurse's role is to prioritize, assess, teach, plan, administer medications, and evaluate. We do not need to know the surgical steps of a gastrectomy.

  • Question: Which is more important for the patient whose tongue was removed: communication or nutrition?

    • Response: Communication. You need to be able to communicate with the patient to assess them and address their needs before or during the feeding process.

  • Question: Can a patient eat while on a tracheostomy?

    • Response: Yes, if the balloon is inflated, though they may not tolerate it well. Nutrition is an important part of the care for several days in the hospital.