CONDITIONS TREATED

Gastrointestinal Cancers

Bowel Cancer

Bowel cancer is common in the UK with around 30,000 cases being diagnosed every year. It affects men and women equally and as always, early diagnosis is very important, giving a far greater chance of a cure. Most bowel cancers begin from pre-cancerous polyps, but in some cases the disease may be inherited.

Symptoms

The symptoms vary from no symptoms at all, to rectal bleeding, a change in bowel habits, weight loss, or anaemia. On occasions, a GP may detect an abdominal swelling.

Diagnosis

Diagnosis is almost always carried out with a colonoscopy using an endoscope which allows a consultant to see the entire length of the colon. Following the identification of a cancer, the consultant will arrange a CT or MRI scan to check whether the cancer has spread to other parts of the patient's body. When the results of all these tests are obtained, a multi-disciplinary team with often include a gastroenterologist, a surgeon, and an oncologist, will meet to decide on the best form of treatment.

Treatment

The most effective treatment for bowel cancer is the surgical removal of the affected part of the bowel. If the disease has spread, then chemotherapy and radio therapy may be used. Sometimes chemotherapy can be used to shrink a localised tumour before surgery to give a better chance of removing all of the affected tissue. If the cancer has spread to the liver or lungs, further surgery by relevant specialists may be needed. If the cancer is not treatable then the patient will be referred to the palliative care team.

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Cancer of the Oesophagus

The oesophagus, or gullet, is a long, muscular tube that connects your throat to your stomach. It is at least 12 inches (30cm) long in adults. When you swallow food it is carried down the oesophagus to the stomach, and the walls of the oesophagus contract to move the food down. A tumour can occur anywhere along the length of the oesophagus.

Cancer of the oesophagus is becoming more common in Europe and North America with men affected more than women. It occurs generally in older people. The cause is unknown but one type of oesophageal cancer, known as adenocarcinoma, appears to be more common in people who have long-term acid reflux, which is the backflow of stomach acid into the oesophagus. Damage to the oesophagus caused by acid reflux is known as Barrett's oesophagus. Over a long period of time a small number of people with this condition, approximately 1 in 100, may develop a cancer of the oesophagus.

Another type of oesophageal cancer called squamous carcinoma is more common among smokers and people who drink a lot of alcohol, especially spirits, or those who have a poor diet. Other conditions affecting the oesophagus, such as achalasia, may also very occasionally lead to cancer.

For the most part, cancer of the oesophagus is not caused by an inherited faulty gene.

Symptoms of cancer of the oesophagus
Oesophageal cancer may cause no symptoms until it begins to obstruct passage of food and fluids down the gullet, or to make swallowing difficult. Difficulty in swallowing is the most common symptom. Often, there is a feeling that food is sticking on its way down to the stomach, although liquids may be swallowed easily at first. There may also be some weight loss, and possibly some pain or discomfort behind the breastbone or in the back. There may be indigestion or a cough. Many of these symptoms can be caused by conditions other than cancer, but you should always tell your GP, particularly if they do not go away after a couple of weeks.

Diagnosis
There are two main tests for diagnosing cancer of the oesophagus:

  • Endoscopy
  • Barium swallow and X-ray

Upper gastrointestinal endoscopy enables the consultant to look directly at the oesophagus using a thin flexible tube called an endoscope. The endoscope has a tiny camera and a light on the end. If necessary, the doctor can take a small sample of the cells (a biopsy) to be examined under a microscope. This can usually confirm whether or not there is a cancer.

Alternatively, a liquid barium solution is swallowed, which shows up on x-ray. The consultant can watch the barium as it flows down the oesophagus towards the stomach while at the same time x-ray pictures are taken of the oesophagus

Treatment
Cancer of the oesophagus can be treated using surgery, chemotherapy or radiotherapy. The choice of treatment will depend upon the exact type of oesophageal cancer, its stage of development, position and size, as well as age and general health. The treatments can be used alone or combined.

Other treatments may be used to ease any swallowing difficulties you may have. These include: intubation or stenting (inserting a tube into the oesophagus to keep it open), dilatation (stretching the oesophagus), laser treatment and photodynamic therapy.

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Neuroendocrine (carcinoid) Tumours

Neuroendocrine tumours are relatively rare tumours however the incidence has increased over the last 20 years from approximately 2 per 100,000 to 4 per 100,000 per year. These tumours can be found anywhere in the body. They are classified according to their site of origin and whether they are functioning (hormone secreting) or non-functioning (non-hormone secreting). There are many types of neuroendocrine tumours including: medullary thyroid cancers, paragangliomas, phaeochromoctomas, bronchial carcinoids and the most common gastroenteropancreatic (GEP) tumours which encompass pancreatic islet cell tumours (e.g. insulinoma, gastrinoma, VIPoma, glucagonoma and non-functional tumours) as well as gastrointestinal carcinoid tumours originating in the foregut, midgut or hindgut.

For the optimal management of NETs, the following strategy is suggested:(i) suspect the diagnosis; (ii) perform appropriate biochemistry profile including urine 24 hour 5 hydroxyindole acetic acid (5HIAA) and serum hormone including chomogranin A measurements; (iii) assessment of histopathology to confirm diagnosis and determine aggressiveness of the disease e.g. features of tumour differentiation, invasion and proliferation index; (iv) determine the presence of inherited disorder such as Multiple Endocrine Neoplasia type 1 (MEN-1) or the Von Hippel-Lindau syndrome; (v) determine the site and extent of disease using for example contrast CT or MRI, as well as the most sensitive modality the Indium-111 Octreotide scan; (vi) treat the symptoms or excessive hormonal state, usually involving somatatostatin analogue e.g. Octreotide or Lanreotide; (vii) treat the disease if possible with curative surgery otherwise consider surgical debulking. Non-surgical treatments of metastatic disease include: somatostatin analogues, interferon alpha, chemotherapy, hepatic artery embolization and radionuclide therapies such as I-131 MIBG and Yttrium-90 DOTA Octreotide; and (viii) all patients will require long term follow-up preferably within treatment protocols.

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Pancreatic Cancer

Cancer of the pancreas is quite rare, developing in about 1 in 10,000 people each year in the UK. There are several types of pancreatic cancer, but the most common, more than 9 in 10 cases is called ductal adenocarcinoma.

Ductal adenocarcinoma of the pancreas develops from cancerous cells in the pancreatic duct. As the tumour grows it can block the bile duct or the main pancreatic duct. This stops the drainage of bile or pancreatic fluid into the duodenum.

The cancer then spreads deeper into the pancreas. It may even pass through the wall of the pancreas and affect nearby organs such as the duodenum, stomach or the liver.

In addition, some cells may break off into the lymph channels or bloodstream. The cancer may then spread to nearby lymph nodes or spread to other areas of the body (metastasise).

Symptoms
The pancreas is a large and important gland which helps to digest food and produces insulin, the main chemical for balancing the sugar level in the blood.

The pancreas is a solid gland about 10 inches (25cm) long behind the stomach and is shaped like a tadpole. Its head is just to the right of the mid-line and its body and tail point upwards at an angle so that the tail is situated just beneath the extreme edge of the left side of the ribs. The head is closely attached to the first part of the small intestine (duodenum), into which the stomach empties food and liquid, already partially digested. It is to this partially digested food that the pancreas adds its digestive enzymes.

The pancreas makes a number of different enzymes each of which is responsible for breaking down the different types of food into small particles that can be absorbed. The enzymes are made in small glands within the pancreas and travel along increasingly large tubes until finally they reach the main pancreatic tube. This connects the gland to the first part of the bowel where food passes after it has gone through the stomach.

In most cases, a tumour develops first in the head of the pancreas. A small tumour often causes no symptoms. As the tumour grows it tends to block the bile duct. This stops the flow of bile into the duodenum which leads to jaundice which makes a patient's skin turn yellow; turns urine a dark colour and turns faeces a pale colour. A patient may also experience generalised itching, caused by bile in the bloodstream.

As the cancer grows in the pancreas, further symptoms that may develop include:

  • Pain in the upper abdomen. Pain in the middle of the back can also develop if the tumour spreads backwards.
  • General malaise and a loss of weight. These symptoms are often the first to develop if the cancer develops in the body or tail of the pancreas (when the bile duct is not blocked).
  • The patient may not digest food very well as the amount of pancreatic fluid will be reduced. This can cause smelly pale faeces, and weight loss.
  • Diabetes sometimes develops if nearly all the pancreas is damaged by the tumour.
  • A tumour can trigger also inflammation of the pancreas - 'acute pancreatitis' causing severe abdominal pain.

Diagnosis
If pancreatic cancer is suspected, a patient will be given blood tests and an ultrasound scan. This can be followed by a CT scan together with an ERCP (Endoscopic Retrograde Cholargio Pancreatography). ERCP uses an endoscope and X-rays to examine damage to the pancreas. The endoscope can also take a sample or biopsy to confirm the presence of cancer.

Treatment
Treatment options include surgery, chemotherapy and radiotherapy. The treatment advised for each case depends on a number of factors such as how large the cancer is, whether it has spread, and the general health of the patient.

Most cancers of the pancreas are advanced before they cause symptoms and are diagnosed. A cure is unlikely in most cases. However, treatment may slow down the progression of the cancer.

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Rectal Cancer

Rectal cancers are common in the UK with a similar number of cases to cancer of the bowel.

Symptoms
The common symptoms of rectal cancer are bleeding combined with a change of bowel habits such as loose stools continuing for longer than six weeks together with the need to visit the toilet more frequently than normal. Rectal pain and sometimes constipation can also indicate a problem that needs early investigation.

Diagnosis
The diagnostic tests include blood and stool tests together with a sigmoidoscopy or colonoscopy carried out under local or general anaesthetic. The consultant will also take tissue samples for examination. If a cancer is discovered, then the consultant may request a CT or MRI scan to see if the cancer has spread.

Treatment
Once the size and particular stage of development of the cancer has been identified the patient may be given chemotherapy or radiotherapy to shrink the tumour before surgery.

Surgical techniques are now much more advanced than before with a far higher prevention of recurrent disease. There can still be some complications depending on the size of the tumour and complexity of the surgery.

Surgery can be followed by chemotherapy and/or radiotherapy.

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Stomach Cancer

There are a number of different types of stomach cancer, each with different causes. Cancers may begin as a result of chronic inflammation, ulcers, large polyps or as a result of pernicious anaemia. Smoking or eating food with a high salt or high nitrite content are also associated with a higher incidence of stomach cancers but by and large, stomach cancer is not hereditary.

Symptoms
The earlier cancer is diagnosed, the better the chances of a cure and so recognising the symptoms and discussing this with your doctor right away is very important.

  • indigestion that does not go away
  • loss of appetite
  • difficulty in swallowing
  • loss of weight
  • feeling bloated after eating
  • feeling sick (nausea) or being sick (vomiting)
  • heartburn
  • blood in the stools or black stools
  • tiredness due to anaemia (from bleeding from the wall of the stomach)

Many of these can be caused by a number of illnesses other than cancer. Most people who see their GP with these symptoms will not have cancer. It is very important to have tests right away and to find the cause of the symptoms.

Diagnosis
Occasionally a lump can be felt in the abdomen, but other tests are always needed.

Endoscopy allowing the doctor to see inside the stomach is the main diagnostic method and a camera is passed via the mouth and into the stomach under local anaesthetic. A small sample of tissue is taken for examination under a microscope (histology) and a test is taken for Helicobacter pylori, a bacterium which can infect the stomach and is thought to increase the risk of stomach cancer.

The second diagnostic tool is a CT scan – this is an X-Ray which takes 3 dimensional pictures of the chest, abdomen and pelvis areas. The CT scan allows a gastroenterologist to see whether a cancer has spread to other parts of the body.

Treatment
Once checks have been made that it has not spread anywhere else, most stomach cancers will be removed by surgery. Either a part of the stomach or the whole stomach is removed, with lymph glands that are close by. The stomach or gullet is then joined to the bowel. Once the cancer has been removed it is examined closely under the microscope to decide exactly what stage it is at. If the cancer is at an early stage and has not spread through the stomach wall, then no further treatment may be necessary. If the cancer has spread through the wall, or involved lymph glands a patient may be offered further treatment such as chemotherapy, radiotherapy or a combination of both. Sometimes chemotherapy is given before surgery in order to shrink a tumour.

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