Gastro-intestinal malignancy: Diagnostic clues for the primary health

practitioner

Rautenbach PS and Baigrie RJ.

Department of Gastro-intestinal Surgery, Groote Schuur Hospital, UCT

Correspondence: lomon@vodamail.co.za

robertb@surgcare.co.za

Up to sixty per cent of the primary health practitioner's patients will present with gastrointestinal

(GI) symptoms [1]. In only a small minority will the clinical presentation mandate urgent

investigations or referral, for example: peritonitis, abdominal distension, jaundice and GI

haemorrhage. The remainder will present with non-specific symptoms and selecting those with

possible underlying malignancy remains a challenge.

This chapter provides a systematic approach to clinical symptoms and signs (Table 1), and their correlation with malignancies is discussed in the remainder of the chapter. Not included are malignant diseases of the liver, biliary tree and pancreas where the commonest symptom is jaundice, most promptly assessed by an abdominal ultrasound and liver function tests.

Clinical Assessment

The key is a good history, and this requires a good listener because GI symptoms are usually vague

and poorly described, for example: “I’ve got a pain in my stomach, Doctor”. Included should be a

family history, past surgical history and medication, many of which have GI side-effects.

Examine the patient supine, with their abdomen and groins exposed. General GI findings include

weight loss, jaundice, a coated tongue, supraclavicular and inguinal nodes. Four quadrant abdominal

palpation and percussion may reveal a mass, localised tenderness and distinguish gas (tympanic

percussion) from ascites (shifting dullness and fluid thrill) in the distended abdomen. Gentle

palpation detects tenderness and a mass better than firm deep palpation, which is seldom helpful

and usually uncomfortable. A digital rectal examination (DRE) is always advised but is mandatory for

rectal bleeding. Only two things are palpable in the rectum, faeces or something sinister. Internal

haemorrhoids or piles are impalpable. Blood on the glove should always be regarded as sinister.

Signs of disseminated malignancy include a VT node, a Sister Mary Joseph nodule (an umbilical

deposit), pelvic and ovarian deposits (Kruckenberg tumours) which DRE may detect as a mass in the

Pouch of Douglas, also known as a Blumer's shelf.

Table 1: Symptoms and Signs [1]

General Weight loss

Pallor

Jaundice

Lymphadenopathy

Abdominal pain

Abdominal distension

Abdominal mass

Ascites

Upper GIT Dysphagia

Dyspepsia

Heartburn

Nausea and vomiting

Melena stool

Lower GIT Altered bowel habit

Bleeding per rectum and melena

Mass

Incontinence

Anus Mass

Pain

Bleeding tags

Non – healing fistula or fissure

GENERAL

1. Abdominal pain

While it should always be taken seriously, abdominal pain is often functional and is also the primary symptom of irritable bowel syndrome (IBS). It is a rare presenting symptom of GI malignancy unless associated with alarm symptoms. Eliciting the nature of the pain, often from the patient's muddled description, is worth the patience. For example, progressively severe pain, which may be cramping or radiating to the back, is more sinister than intermittent lower abdominal recurrent ache. It is important to elicit the history of a consistent change in bowel habit, early satiety, weight loss, pallor

or coated tongue. These are rarely present in functional pain.

Approach:

In the presence or absence of any suggestive examination findings, abdominal ultrasound (US) should be the first investigation for abdominal pain, sometimes with an Hb, CRP and hepatocellular enzymes. It is not productive or cost effective to request a battery of random blood tests, such as tumour markers, from which the yield is vanishingly low.

2. Anaemia

Gastrointestinal blood loss results in iron deficiency anaemia and the anaemia should be confirmed as such. It results from overt or occult blood loss, intestinal iron malabsorption (as in coeliac disease or gastric atrophy or after gastric bypass surgery), or an inadequate diet.

Approach: All patients with unexplained iron deficiency anaemia should undergo GI tract screening, usually

with upper endoscopy and colonoscopy. In a prospective study of 100 patients with iron deficiency

anaemia, GI tract lesions were found in 62 patients, with 36 having lesions in the UGI tract (mostly

ulcers), 25 in the colon (mostly cancer), and 1 in both the upper GI tract and colon [2]. A prescription

of iron supplements in uninvestigated iron deficient anaemia may delay diagnosis, sometimes long

enough to preclude the opportunity of curative surgery.

UPPER GIT

1. Dysphagia

Dysphagia originates from the Greek dys (difficulty, disordered) and phagia (to eat). Benign causes

include achalasia, pharyngeal pouch and peptic strictures from gastro-oesophageal reflux disease

(GORD) [3]. The patient with oesophageal cancer may (not always) report weight loss.

Squamous carcinoma is the commonest type of oesophageal malignancy worldwide [4]. The highest

incidence, with rates greater than 1 per 1,000, is in the “Asian oesophageal cancer belt,” extending

from northern Iran through the central Asian republics to north-central China. The intermediate risk

regions include parts of east and southeast Africa e.g. eastern Kenya, Zimbabwe, and the eastern

part of the Eastern Cape (formerly Transkei) in South Africa. The risk of oesophageal cancer is

increased in men, smokers, high consumers of alcohol, and a long-standing history of heartburn.

Approach:

Dysphagia mandates investigation. Upper endoscopy is more accurate than barium swallow,

although it could miss achalasia and may be challenging to perform when an unsuspected

pharyngeal pouch is present.

2. Heartburn and Regurgitation

Heartburn is one of the most common GI complaints. It is poorly named and has many synonyms, including indigestion. The commonest cause is GORD, however, motility disturbances, e.g. achalasia, and oesophagogastric cancer may also present with this symptom. Cardiac or biliary disease (symptomatic gallstones) should be considered in the differential diagnosis.

Approach: Endoscopy is reserved for patients with alarm symptoms for example: dysphagia, weight loss, anaemia, hematemesis, epigastric or a cervical mass (Table 2). Most guidelines also recommend endoscopy to screen for Barrett's esophagus in patients with chronic reflux symptoms; particularly those older than 50 years [5]. The spontaneous resolution of longstanding heartburn may indicate development of Barrett's metaplasia and mandates endoscopy.

Young patients (under 45) with typical heartburn do not need endoscopy unless they dont respond promptly to PPI therapy [5]. In addition to endoscopy, US will exclude gallstones.

3. Dyspepsia

Dyspepsia (from the Greek words dys and pepse meaning “difficult digestion”) is not a term usually

volunteered by patients. Rather, it is a symptom group considered to be specific for a

gastroduodenal origin, and is now considered to include only bothersome postprandial fullness,

early satiety, epigastric pain and burning. Patients may report many other symptoms coexisting with

dyspepsia.

The most common organic causes are peptic ulcer disease, GORD and gallstones. Malignancies of the

upper gastrointestinal tract and coeliac disease are rare causes [6]. Those found not to have an

organic cause of their symptoms are said to have functional dyspepsia [1].

The risk of gastric and oesophageal malignancies in dyspeptic patients is estimated at less than 1%, however gastric cancer remains the second leading cause of cancer mortality worldwide [7]. It is usually an adenocarcinoma, and is associated with age, cigarette smoking, H. pylori infection, a family history, previous gastric surgery, and migrants from areas endemic for gastric malignancy.[1]

Approach:

When dyspeptic symptoms are persistent, or associated with even a single alarm symptom, then US,

liver function tests (LFTs), a full blood count (FBC) and selective endoscopy will screen malignancy

effectively. Guidelines advocate prompt endoscopy when risk factors such as NSAID use, age above

45 years or alarm symptoms (Table 2) are present [8].

The vast majority of malignancies occur in patients older than 45 years and guidelines do not support early endoscopy as a cost-effective, initial management strategy for all patients with uncomplicated dyspepsia [8]. However, young patients also get cancer and persistent symptoms (beyond a few weeks) require investigation.

4. Nausea and Vomiting

Nausea, retching, passive regurgitation, vomiting, a metallic taste and waterbrash are all difficult to

assess and are usually functional, but they may also be symptoms of GI malignancy and many other

conditions, ranging from allergies to a cerebral tumour. A careful enquiry of associated symptoms

may direct the approach.

Vomiting may be a symptom of intestinal obstruction but won’t have concomitant abdominal

distension if the obstruction is in the proximal gut. Gastric, duodenal, or pancreatic malignancies

may cause gastric outlet obstruction, usually manifesting as persistent vomiting. The presence of a

succusion splash is diagnostic. Five per cent of small bowel obstruction is secondary to malignancy

[9]. The more distal the obstruction is in the GI tract, the more likely is a malignant cause and when

associated with marked distension and constipation, a left sided colorectal cancer is most likely.

Haematemesis is most often secondary to benign disease, but the presence of alarm symptoms

(Table 2) raises the suspicion of underlying malignancy.

Approach: Patients with haematemesis should be referred for endoscopy. Persistent vomiting beyond a few days requires investigation, especially in the presence of alarm symptoms (Table 2). If obstruction is suspected, in-patient investigation, while receiving resuscitation, is appropriate. Plain X-ray will usually demonstrate obstruction, but is not always diagnostic, particularly early in its development. Pseudo-obstruction (Ogilvie's syndrome) is an uncommon condition of colonic ileus, usually associated with general ill-health, which is sometimes (potentially disasterously) mistaken for a malignant obstruction.

Table 2: Upper GI alarm symptoms and signs

Weight loss

Pallor, anaemia

Dysphagia

Postprandial vomiting of undigested food

Epigastric mass

Hematemesis

Succusion splash

LOWER GIT

1. Altered bowel habit

There is no useful definition of a "normal" bowel habit, nor of diarrhoea and constipation. Patients may use these words inappropriately, for example a few loose stools over a few days may be called diarrhoea, while a failure to defaecate for a day might be described as constipation by the patient. The key is to enquire carefully about a change in defaecatory pattern.

Constipation is particularly prevalent in women, children and the elderly, and the description may

include straining, lumpy or hard stool or a sensation of anorectal blockage. Unintentional weight

loss, rectal bleeding, changes in the calibre of the stool, new onset abdominal pain, and family

history of colon cancer, are alarming features (Table 4). Longstanding constipation, variably

refractory to conservative measures, is suggestive of a functional cause.

Approach: Patients, particulary over 45 years, with a significant or new onset change in bowel habit, persisting

for about 4 weeks, should be investigated [10][15]. Weight loss, rectal bleeding, loudly audible

bowel sounds (borborygami) and new onset abdominal pain are associated alarm symptoms,

Abdominal X-Ray may show marked faecal loading, but colonoscopy (or flexible sigmoidoscopy in the

young patient) is the best investigation. CT Colonography has an expanding application, but does not

have the colonoscopic advantage of tissue sampling. [11] Faecal impaction or a mass will be

detected by DRE.

2. Bleeding per rectum

Bright red blood most often originates from the anorectum (rarely it can be due to a massive upper

GI tract bleed). Maroon or altered blood at defaecation is likely to originate in the left colon.

Melaena (black, tarry stools) can originate from the upper GI tract, small bowel, or a proximal

colonic source.

Twenty per cent of patients presenting with lower GI bleed have underlying colon polyps and

colorectal cancer [12]. Benign pathology is much more common and includes haemorrhoids and

fissures locally with colitis, diverticular bleeding and angiodysplasia more proximally. The

commonest upper GI causes are peptic ulceration, gastritis, erosions and oesophagitis. Small bowel

malignancy is rare but includes lymphoma, carcinoid tumor, metastases, Kaposi's sarcoma and

primary adenocarcinoma.

Approach:

Gastrointestinal haemorrhage mandates admission for resuscitation and investigation. Unless a

clearly responsible ulcer is identified at endoscopy, colonoscopy should follow. A finding of gastritis, erosions, oesophagitis and superficial ulceration requires colonoscopy to exclude a lower GI cause which may be a synchronous cancer. The major problem with non- haemorrhagic rectal bleeding is distinguishing between those patients who can be safely diagnosed as having bleeding from haemorrhoids or another minor peri- anal complaint, and those with an underlying sinister cause. Unfortunately both cancer and haemorrhoids are common, and can co-exist. Therefor all patients with anorectal bleeding require a careful history, digital examination and a proctosigmoidoscopy [15].

Table 3: Indications for Colonoscopy in patients with rectal bleeding [13]

• no local cause identified

• a patient 50 years or older

• any alert symptoms:

o change in bowel habit

o loss of weight

o iron deficiency anaemia

o family history of colorectal cancer

ANUS

Anal cancers are rare. They account for 1.5% of gastrointestinal cancers in the United States with 3500 new cases each year [14]. Increasingly promiscuous sexual practices, however, may account for the increased prevalence of Human papilloma virus (HPV) condylomata and cancer [14]. Tumours arising in the distal anal canal usually are keratinizing squamous cell carcinomas.

Approach:

All patients with anorectal complaints require abdominal, groin and DRE. Anal pathology drains to

the inguinal nodes. Benign skin tags should not be confused with HPV condylomata which are

premalignant. The presence of an anal or rectal mass mandates urgent referral, irrespective of age. If

the patient cannot tolerate DRE, then cancer or fissure is likely. A suspicion of cancer mandates an

examination under anaesthesia (EUA). When a fissure is visible on anal distraction and is confidently

diagnosed, a digital examination can be avoided at the first consultation. A failure of fissure to

respond promptly to topical therapy mandates an EUA. Beware of the non-healing fistula or fissure;

these lesions should be biopsied.

Table 4: Lower GI alarm symptoms and signs

Weight loss

Altered bowel habits

Rectal bleeding or melena

Persistent pain

Rectal mass

CONCLUSION

Delayed diagnosis of GI malignancy is common, resulting in late stage pathology and a decreased

chance of cure. While patients may contribute to the delay, the primary health practitioner is

frequently responsible. This can be improved by the recognition of obvious alarm symptoms,

recalling patients for review, and a proper general and abdominal examination (as in the final

undergraduate exam that we all passed!). Remember - clinicians are not in the business of making

mistakes and a resistance to investigate further (US is the simplest and most available) or refer for a

second opinion, will contribute to delays in diagnosis.

Take Home Message:

1. Upper GI alarm symptoms: weight loss, dysphagia, anaemia.

2. Lower GI alarm symptoms: change in bowel habit, bleeding and persistent pain.

3. Spontaneous resolution of longstanding heartburn mandates endoscopy.

4. New onset altered bowel habit, persisting beyond the short term (2-4 weeks) requires investigation.

5. All GI bleeding requires investigation.

6. Fe deficient anaemia must not be treated until the cause has been determined

7. Young people also get cancer.

8. Patients with persistent GI symptoms require investigation, even if they are not alarm symptoms; review patients at 4-6 weeks after presentation.

9. Abdominal US is cheap, effective, reassuring and readily available.

10. "If you don’t put your finger in it you will put your foot in it".

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Formatted: Indent: Left: 0 cm,Hanging: 1.27 cm