Cancer oesophagus

Incidence More common in men than women Usually in the fifth decade of life Aetiology Chronic irritation – chronic oesophagitis Alcohol – smoking – (tobacco) Opium pipes Excessively hot beverages Nutritional deficiencies especially lack of fruits and vegetables (fruits and vegetables promote repair of irritated tissue)

Smoking

Chronic oesophagitis may predispose to ca oesophagus

Usually squamous cell epidermoid type Pathophysiology Usually squamous cell epidermoid type Tumour cells spread beneath the oesophageal mucosa or directly into, through, and beyond the muscle layers into the lymphatics In late stages obstruction of the gut Perforation may occur into the mediastinum and erosion into the great vessels

Clinical manifestations Dysphagia Initially to solid foods and eventually to liquid food. A feeling of a mass in the throat Painful swallowing Substernal pain or fullness. Regurgitation of undigested food with foul breath Hiccups Intermittent and increasing difficulty in swallowing Obstruction of the oesophagus  regurgitation of food and saliva – haemorrhage may take place – respiratory difficulty

Investigations Oesophagoduodenoscopy – gastroscopy Biopsy and brushings Bronchoscopy – esp. in tumours of middle and upper third Mediastinoscopy – to determine operability Other routine blood investigations Ultrasound scan – to determine secondaries in liver

Normal Oesophagus

Cancer Oesophagus

Barium Swallow showing cancer oesophagus

Ca oesphagus before and after chemoradiotherapy Rat tail appearance

Ca oesophagus lower end irregular and proximal dilatation

Management Surgery – oesopahgectomy, free jejunal graft, colon or elevation of stomach – tumours of the lower thoracic oesophagus are more amenable to surgery than are tumours located higher in the oesophagus Radiation Chemotherapy A combination of these modalities

Cat scan machine

Lipoma oesophagus

Other modalities of treatment Preoperative radiation therapy and chemotherapy may be given Palliative treatment to keep oesophagus open to assist with nutrition to control saliva Dilatation of the oesophagus Laser therapy Placement of an endoprosthesis (stent) Radiation and chemotherapy

Self expanding metal stent

Prognosis Surgical resection – high mortality – infection – pulmonary complications – leak – postoperatively a nasogastric tube will be in place which should not be manipulated – NPO until X-ray studies confirm that the anastomosis is secure and not leaking

Nursing Management Improve patient’s nutritional status Prepare for surgery or radiation therapy or chemotherapy High calorie, high protein diet in liquid or soft form Total parenteral nutrition Explain the various procedures and equipments that are going to be used

Nursing in Fowler’s position to assist in preventing reflux of gastric secretions. Observe for regurgitation and dyspnoea For aspiration pneumonia Monitor temperature and look for seepage of fluids into the mediastinum If grafting has been done watch for viability Doppler study to assess blood supply to the graft. Nasogastric tube if displaced make no attempt to replace Nasogastric tube is removed after 5-7 days Ba swallow performed before feeding

Patient is encouraged to eat after removal of the nasogastric tube Chewing – Important Home cooked food – family involvement encouraged. Deal with excessive saliva – to prevent aspiration pneumonia