CARCINOMA OF OESOPHAGUS

INTRODUCTION The commonest site is the lower third of the oesophagus followed by the middle third annd upper third. Postcricoid carcinoma usually in female and is part of the Plummer-Vinson syndrome.Squamous cell carcinoma occurs in the upper and middle thirds but adenomacarcinoma may occur in the lower third associated with areas of gastric mucosa(Barretts oesophagus) or by growth of a carcinoma of the cardiac area of the stomach into the oesophagus. Can be spread by the following: -local invasion into surrounding structures,trachea,lung and aorta.(massive haemmorrhage). -lymphatic to paraoesophageal nodes.supraclavicular and abdonminal nodes. -blood stream to liver and lung. DEFINITION A benign or malignan carcinoma that occur at the oesophagus. ETIOLOGY The etiology of esophageal carcinoma is thought to be related to exposure of the esophageal mucosa to noxious or toxic stimuli, resulting in a sequence of dysplasia to carcinoma. PATHOPHISIOLOGY Pathophysiology The most common types of esophageal carcinoma are squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma The normal esophagus is lined by stratified squamous nonkeratinizing epithelium. Squamous cell carcinoma arises from this epithelial layer in response to chronic toxic irritation. Alcohol, tobacco, and certain nitrogen compounds have been identified as carcinogenic irritants. Certain medical conditions predispose patients to the development of esophageal squamous cell carcinoma. These include achalasia, lye strictures, head and neck tumors, celiac disease, Plummer-Vinson syndrome, tylosis, and prior exposure to radiation.Plummer-Vinson syndrome consists of dysphagia, iron-deficiency anemia, and esophageal webs. Patients with this syndrome have an increased incidence of postcricoid squamous cell carcinoma. Infection with human papillomavirus,has been implicated in the pathogenesis of esophageal squamous cell carcinoma.

Adenocarcinoma Adenocarcinoma, which is most common in the mid and distal esophagus, arises from abnormal esophageal mucosa in a well-characterized sequence. In reaction to chronic gastroesophageal reflux, metaplasia of the normal stratified squamous epithelium of the distal esophagus occurs, resulting in a specialized intestinal glandular epithelium containing goblet cells called Barrett epithelium. Further genetic alterations in this epithelium lead to dysplasia, which may progress from low-grade to high-grade dysplasia and,finally to adenocarcinoma. Gastroesophageal reflux disease (GERD) is the most important factor in the development of Barrett epithelium. Therefore, patients with Barrett epithelium are advised to undergo periodic surveillance esophageal endoscopy with biopsy. Although alcohol use has not been strongly linked to the development of esophageal adenocarcinoma, smoking has been identified as a risk factor. Obesity, certain medications and environmental exposures, and diet and nutritional habits have been implicated as additional risk factors. SIGNS & SYMPTOMS -Dysphagia,usually rapid onset. Initially for solids then for liquids. -Weight loss,anorexia. -Anaemia. -Palpable supraclavicular nodes. -Palpable irregular liver. INVESTIGATION -Full Blood Count(FBC) To identify the increasing or decreasing of blood cells.

-Urea & Electrolytes (U&E) To identify urea and electrolytes rate in body.

-Liver Function Test (LFT) To investigate the function of liver.

-Barium swallow To detect the stricture in oesophagus.

-Upper Gastrointestinal Endoscopy & Biopsy To identify the specific area of the cancer and to identify the type of cell.

-Bronchoscopy To exclude invasion of oesophagus by primary lung tumor or vice versa.

-Ultrasound To exclude secondaries. DIFFERENTIAL DIAGNOSIS -Corrosive oesophagitis. -Achalasia -Plummer-Vinson Syndrome. COMPLICATION Metastasis to other organ such as liver,lung,intestitial. MANAGEMENT -Patient admitted to ward. -Rest in bed. -Check for vital signs:blood pressure,temperature,pulse rate,and respiration rate. -Pre-operative management: Ask for consent. Explain to patient and families about the procedure to be done. Nil by mouth(4-6 hours). On IV fluids to maintain hydration anf liquids in body. Pre-medication: analgesics,antipiretic,antihypertensive,anaesthetic,etc. Laboratory investigation: blood test,urine test.etc. Cross match in case of blood loss during procedure. Phisiotherapy:breathing exercises. -Treatment: Resection. If the tumour is inoperable,an expandable metal stent may be placed through the tumour using a fibreoptic endoscopic. To relieve dysphagia:laser therapy. Radiotherapy for primary or palliative treatment for squamous cell carcinoma. Chemotherapy. -Post-operative management: Monitor vital signs every 15minutes until patient stable. Early mobilization:passive exercises followed by active exercises. Continue IV fluids. Monitor intake/output chart. Medications:analgesics,antibiotics,or any routine medications as indicated. -Nursing care: Take high protein diet for healing process. Practice good hygiene habit. Exercice regulary. -Health education:

Eat medicine as prescribed by doctor. Avoid stress. Practice healthy lifestyle. Come for TCA at date appointed.

PROGNOSIS Prognosis is poor. Most patient survive less than 6 monthsif the primary is non-resectable.the 5 years survival following resection is less than 20%.