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Causes and symptoms
- Tobacco and alcohol consumption are the major risk factors, especially for squamous cell carcinoma. Smoking and alcohol abuse each increase the risk of squamous cell carcinoma by five-fold. The effects of the two are synergistic, in that the combination of smoking and alchohol increases the risk by 25- to 100- fold. It is estimated that drinking about 13 ounces of alcohol every day for an extended period of time raises the risk of developing esophageal cancer by 18%. That likelihood increases to 44% in individuals who also smoke one or two packs of cigarettes a day. Smokeless tobacco also increases the risk for esophageal cancer.
- Gastroesophageal reflux is a condition in which acid from the stomach refluxes backwards into the lower portion of the esophagus, sometimes causing symptoms of heartburn. In some cases of gastroesophageal reflux, the chronic exposure to acid causes the inner lining of the lower esophagus to change from squamous cells to glandular cells. This is called Barrett's esophagus. Patients with Barrett's esophagus are roughly 30 to 40 times more likely than the general population to develop adenocarcinoma of the esophagus.
- A diet low in fruits, vegetables, zinc, riboflavin, and other vitamins can increase risk of developing to esophageal cancer.
- Caustic injury to the esophagus inflicted by swallowing lye or other substances that damage esophageal cells can lead to the development of squamous cell esophageal cancer in later life.
- Achalasia is a condition in which the lower esophageal sphincter (muscle) cannot relax enough to let food pass into the stomach. Squamous cell esophageal cancer develops in about 6% of patients with achalasia.
- Tylosis is a rare inherited disease characterized by excess skin on the palms and soles. Affected patients have a much higher probability of developing esophageal cancer than the general population. They should have regular screenings to detect the disease in its early, most curable stages.
- Esophageal webs, which are protrusions of tissue into the esophagus, and diverticula, which are out-pouchings of the wall of the esophagus, are associated with a higher incidence of esophageal cancer.
esophageal cancerGI disease A malignancy of the esophagus, most commonly, SCC and adenoCA Epidemiology ♂:♀, 3:1; age 55-70; ↑ in China, Japan, Scotland, Russia, Scandinavia; ±12,000 new cases/yr US; blacks have a 4-fold greater risk than whites–rate 1/105 ♀, 4/105 ♂ Risk factors Alcohol, tobacco use, poor nutrition, Hx of achalasia, corrosive esophagitis, Barrett's esophagus, tylosis palmaris et plantaris Clinical Dysphagia, retrosternal discomfort and pain, pressure, burning, and a sensation of food being stuck, eventually, narrowing of esophagus becomes severe, with choking, vomiting, weight loss Types SCC, ≥ 70%; adenoCA in Barrett's esophagus–10-20% Diagnosis Barium swallow to ID lesions arising in the esophageal mucosa, upper GI endoscopy/esophagoscopy with Bx and cytology brushings Staging CT, MRI, ultrasound Treatment Cisplatin, 5-FU, RT–5000 cGy is better than RT alone–6400 cGy for local control of CA, metastasis, ↑ survival, but ↑ side effects Prognosis Median survival, 10 months; 5-yr survival, 20–36%
|Mean LOS:||15.4 days|
|Description:||SURGICAL: Stomach, Esophageal, and Duodenal Procedure With Major CC|
|Mean LOS:||5.5 days|
|Description:||MEDICAL: Digestive Malignancy With CC|
Carcinoma is the most common cause of obstruction of the esophagus. Approximately half of all esophageal cancers are squamous cell carcinomas, which usually occur in the middle and lower two-thirds of the esophagus and are often associated with alcohol and tobacco use. The remaining 50% are adenocarcinomas, which generally begin in glandular tissue of the esophagus. Adenocarcinomas are associated with Barrett’s esophagus, a condition that occurs because of continued reflux of fluid from the stomach into the lower esophagus. Over time, reflux changes the cells at the end of the esophagus. Adenocarcinomas may invade the upper portion of the stomach.
Esophageal tumors begin as benign growths and grow rapidly because there is no serosal layer to inhibit growth. Because of the vast lymphatic network of the esophagus, esophageal cancers spread rapidly, both locally to regional lymph nodes and distantly to the lungs and liver. Complications include pulmonary problems that result from fistulae and aspiration; invasion of the tumor into major vessels, causing a massive hemorrhage; and obstruction and compression of the other structures in the head and neck. Although survival rates are improving, esophageal cancer is usually diagnosed at a late stage, and most patients die within 6 months of diagnosis. It is estimated that 17,990 new cases of esophageal cancer were diagnosed in 2013, and approximately 15,000 people die from the disease each year. The 5-year survival rate for localized disease is 38%. While the survival rates have been improving over the last 50 years, only 15% of whites and 8% of African Americans will survive 5 years after diagnosis.
Although its etiology is unknown, for many years in the United States, the primary risk factors were alcohol and tobacco use. In recent decades, there has been a progressive increase related to gastroesophageal reflux disease. Recently, oral exposure of the human papillomavirus infection has also been identified as a risk factor. In parts of the world where it is most common (Southeast Asia, the Middle East, and South Africa), the disease has been linked to nitrosamines and other contaminants in the soil. It has also been found to have a higher incidence in individuals whose diets are chronically deficient in fresh fruits, vegetables, vitamins, and proteins. Other risk factors include obesity, caustic injuries from lye ingestion, and occupational exposure with perchloroethylene, which is used in the automotive and dry cleaning industries.
Although the exact cause of esophageal cancer is not clear, environmental risk factors appear to be predominant. Epidemiologic studies have found likely autosomal recessive patterns; in Chinese populations, however, the combination of genes and environment may be most likely.
Gender, ethnic/racial, and life span considerations
Cancer of the esophagus usually occurs in men between the ages of 50 and 70. The disorder affects men in a 3:1 ratio to women. African Americans are affected three times as often as European Americans. It is also more common in Asian American males than in the general population. Squamous cell carcinoma is more common in European Americans, whereas adenocarcinomas are more common in African Americans.
Global health considerations
The global incidence of esophageal cancer is 10 per 100,000 males and 5 per 100,000 females, but in some countries with high soil contamination, rates are as high as 800 per 100,000 individuals. In developing nations, females have a higher incidence of the condition than in developed nations, whereas the male incidence of esophageal cancer is approximately the same across nations.
Obtain an accurate history of risk factors, including race, cultural background, use of cigarettes and alcohol, and any esophageal problems. Dysphagia is usually experienced when at least 60% of the esophagus is occluded. Initially, it is mild and intermittent, and it occurs only with solid foods. Patients may report a sensation that “food is sticking in their throat.” Symptoms of the disease soon progress to the inability to swallow semisoft or liquid food, and the patient experiences a severe weight loss, as much as 40 to 50 pounds over 2 to 3 months. Eventually, the patient is unable to swallow her or his own saliva. Also inquire about regurgitation, vomiting, chronic hiccups, odynophagia (painful swallowing), and dietary patterns. Patients may report pain radiating to the neck, jaw, ears, and shoulders.
Dysphagia is the most common symptom. Observe the patient’s ability to swallow food. Note any chronic coughing and increased oral secretions. Listen to the patient’s voice: Tumors in the upper esophagus can involve the larynx and cause hoarseness. Place the patient in the recumbent position; pain, hoarseness, coughing, and potential aspiration often occur in this position. Weigh the patient and determine the patient’s strength and motion of the extremities. Severe weight loss and weakness are common symptoms.
The patient needs to make a psychological adjustment to the diagnosis of a chronic illness that is usually terminal. Evaluate the patient for evidence of altered mood (e.g., depression or anxiety) and assess the coping mechanisms and support systems.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Barium swallow||Normal esophagus||Irregular areas in or narrowing of the esophagus||Locates and describes irregularities in the esophageal wall or fistulae|
|Esophagogastroduodenoscopy||Visualization of a normal esophagus and stomach||Direct visualization of tumor or fistula||Locates the tumor for a biopsy|
Other Tests: Computed tomography scan, endoscopic ultrasound, thoracoscopy, laparoscopy, liver scan, bronchoscopy, magnetic resonance imaging, positive emission tomography
Primary nursing diagnosis
DiagnosisAltered nutrition: Less than body requirements related to dysphagia
OutcomesNutritional status: Food and fluid intake; Nutrient intake; Biochemical measures; Body mass; Energy; Endurance
InterventionsNutrition management; Nutrition therapy; Nutritional counseling and monitoring; Fluid/electrolyte management; Medication management
Planning and implementation
Surgery, radiotherapy, chemotherapy, laser therapy, and endoscopic therapy are all options for treating cancer of the esophagus, and they may be used alone or in combination. Early-stage patients may be treated with endoscopic therapies, such as endoscopic mucosal resection or endoscopic submucosal dissection. Trimodal therapy, which includes chemotherapy and radiotherapy (chemoradiation), followed by surgery is recommended for those who can tolerate this rigorous treatment regime. Preoperative chemotherapy followed by surgery has poorer patient outcomes than trimodal therapy. Two surgical procedures are commonly performed: esophagectomy (removal of all or part of the esophagus with a Dacron graft replacing the part that was removed) and esophagogastrectomy (resection of the lower part of the esophagus together with a proximal portion of the stomach, followed by anastomosis of the remaining portion of the esophagus and stomach). Postoperatively, monitor the nasogastric (NG) tube for patency. Expect some bloody drainage initially; within 24 to 48 hours, the drainage should change to a yellowish-green. Do not irrigate or reposition the NG tube without a physician’s order. Fluid and electrolyte balance as well as intake and output should be monitored carefully. Monitor the patient who has had an anastomosis for signs and symptoms of leakage, which is most likely to occur 5 to 7 days postoperatively. These include low-grade fever, inflammation, accumulation of fluid, and early symptoms of shock (tachycardia, tachypnea).
For patients who are not candidates for surgery but rather for palliation, chemotherapy, radiotherapy, and laser therapy reduce the size of the tumor and provide some relief to the patient. Usually, external beam radiation therapy is used. Normal esophageal tissue is also affected by the radiation, which is given over a 6- to 8-week period to minimize the side effects. Side effects include edema, epithelial desquamation, esophagitis, odynophagia, anorexia, nausea, and vomiting. Although radiation by itself does not cure esophageal cancer, it eases symptoms such as pain, bleeding, and dysphagia.
|Medication or Drug Class||Dosage||Description||Rationale|
|Chemotherapy||Varies by drug||Types of chemotherapy: 5-fluorouracil, capecitabine, cisplatin, carboplatin, docetaxel, bleomycin, mitomycin, doxorubicin, methotrexate, paclitaxel, vinorelbine, topotecan, irinotecan, mitoguazone, epirubicin, porfimer||Kills cancer cells; primary chemotherapy will not cure esophageal cancer unless surgery and/or radiation is also used; preoperatively, chemotherapy may be given to reduce tumor size; approximately 10%–40% of patients will have a significant shrinking of the tumor from these drugs|
Carefully monitor the patient’s nutritional intake and involve the patient in planning their diet. Maintain a daily record of caloric intake and weight. Monitor the skin turgor and mucous membranes to detect dehydration. Keep the head of the bed elevated at least 30 degrees to prevent reflux and pulmonary aspiration. If the patient is having problems swallowing saliva, keep a suction catheter with an oral suction at the bedside at all times. Teach the patient how to clear his or her mouth with the oral suction.
When appropriate, discuss expected preoperative and postoperative procedures, including information about x-rays, intravenous hydration, wound drains, NG tube and suctioning, and chest tubes. Immediately after surgery, implement strategies to prevent respiratory complications.
Provide emotional support. Focus on the patient’s quality of life and discuss realistic planning with the family. Involve the patient as much as possible in decisions concerning care. If the patient is terminally ill, encourage the significant others to involve the patient in discussions about funeral arrangements and terminal care, such as hospice care. Provide a referral to the patient to the American Cancer Society, support groups, and hospice care as appropriate.
Evidence-Based Practice and Health Policy
Wright, C.D., Kucharczuk, J.C., O'Brien, S.M., Grab, J.D., & Allen, M.S. (2009). Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: A Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model. Journal of Thoracic and Cardiovascular Surgery, 137(3), 587–595.
- In a study of 2,315 patients who underwent esophagectomies for esophageal cancer, hospital discharge mortality was 2.7%.
- Major morbidities, including bleeding, anastomotic leak, pneumonia, and re-intubation, occurred in 24% of patients.
- In this sample, morbidity risk increased significantly among patients with insulin-dependent diabetes, hypertension, and steroid use (p = 0.009, p = 0.029, and p = 0.026, respectively).
- Physical assessment data: Ability to eat and swallow, patency of airway, regularity of breathing, temperature, daily weights, breath sounds, intake and output, calorie counts
- Chronologic record of symptoms and response to interventions
- The nature, location, duration, and intensity of pain; response to pain medication or other interventions
- Patient’s emotional response to a poor prognosis and treatment modalities