Week 16 & 17: Upper Gastrointestinal Tract Cancer Complete PDF

Week 16 | Part 1: Gastrointestinal Tract Cancer of metastasis in this area is high because of the ducts, — common  exposure to gastric acid and enzymes kumbaga nag aadapt na  there are more than 200 types of cancer and each one is bile duct and hepat...

Week 16 | Part 1: Gastrointestinal Tract Cancer of metastasis in this area is high because of the ducts, — common  exposure to gastric acid and enzymes kumbaga nag aadapt na  there are more than 200 types of cancer and each one is bile duct and hepatic duct yung esophagus and once nag adapt na ang cellular treated according to the type of cancer, stages of disease, structure ibig sabihin nun meron ng cellular changes = specific genetic mutation associated with cancer and so on abnormal cellular proliferation), Diet, Family History  radiation is generally combined with other treatment (the  Stomach: Obesity (causes inactivity and it makes us consume doctor and patient will decide the best course of treatment more calorie and the body tissue became resistant to insulin based on therapies currently available) and high insulin level in the body increases cell proliferation  pwede din ang clinical trial to gain access to therapy and and promote growth of cancerous cell) , GERD, Diet, development (Malabsorption — particularly Vitamin B 12 absorption  Joint Therapy: integration of immunotherapy and [which causes pernicious anemia] because some areas of chemotherapy in a sample of patient with metastatic, non the stomach that produces the intrinsic factor that is squamous and non small cell lung cancer important in Vitamin B 12 absorption has problem and if effective more than doubling cancer response rate may problem ang stomach cells it can mutate and may  Therapies derived from T Cells: new formed of engineer T progress to cancer cell development), Exposure to cells have exhibited enhance antitumor activity targeting chemicals (such as nitrate and processed food), Family antigens in tumor cells allowing the body immune defenses History to attack the cancer within the patient  Liver: Chronic Liver Injury (which produces inflammation which will lead to hepatocytes regeneration and fibrosis so Anatomy Review | Upper Gastrointestinal Tract magkakaroon na naman ng cellular changes and with Stomach! Pancreas repeated cycle of cellular regeneration and fibrosis, it may  has 2 parts — (1) the head which is the rounded one (2) and  generally common areas that are affected are those which are lead to cell death and eventually leading to liver cirrhosis exposed to gastric acid, enzymes and certain chemicals the tail part [Additional — Hepatitis, Chronic Alcohol Use]), Age,  Take Note: because of the head proximity, its close adjacency from the food that we eat, this area may include: (1) Gender (M > F), Aflatoxin B (in contaminated food products Cardia, (2) Body and (3) Pylorus of the stomach to the stomach (mas malapit sit sa stomach and meron din — hepatocarcinogen that induces hepatocellular  Paano tayo naapektuhan? — because of the Law of Gravity siyang contact sa digestive enzyme) therefore, the head of carcinoma), Family History, where in the stomach content together with the acids the pancreas is the most common site of cancer cells  Pancreas: Age, Gender, Smoking (according to evidence, and enzyme settle in this area because this is the formation cigarette contains nicotine but it does not contribute to  it is difficult to diagnose patients with pancreatic cancer lower portion of the stomach cancer but rather the nitrosamines — toxic and harmful  Gastroesophageal Junction: serves as a sphincter and is because the manifestations may be confused with diabetes content of cigarette that contributes to cellular changes supposed to closed when we digest the food and then food mellitus (DM) so bakit? — because the head of the [during smoking the nicotine reaches the lungs and goes inside the stomach but if in condition such as GERD pancreas is a part that produce most of the pancreatic absorbed by the bloodstream and longer exposure to the acid, enzymes and chemicals come with contact the enzyme and hormones which we all know are important in nicotine leads to higher nicotine retention to the cardia area therefore, it can alter the cell morphology (cell regulating the insulin, so the majority of the function of the esophagus, spleen, secum, and pancreas and study shows structure, shaped, and function of the cell) hence, can pancreas is to control the sugar so kapag may tumor sa that nicotine levels found in pancreatic juices are 17 times predispose the cardia area in cancer formation) head ng pancreas the regulation of the insulin may also be higher in smoker than non smoker]), Diabetes Mellitus impaired so at first, what were treating is the manifestation (according to evidence, those individuals with no history of Liver of diabetes hence, kapag nalaman na cancer na ang cause DM disease may present DM manifestation because of the  one of the major organs in the body and play a role in malala na yung tumor a malignant na altered insulin regulation brought about by the cancer cell metabolism including the medication we take and when tumor therefore making it more difficult to diagnose) , cancer of the liver develop different functions of the liver What Are The Risk Factors? Family History  Esophagus: Age, Smoking (because the smoke we inhale does may be impaired such as — (1) metabolism of waste, (2)  Take Note: Diet and Age are the most predominant risk factor storage of different vitamins that our body needs (such as not only goes to the airway, some of it are ingested upon in the cancer of upper gastrointestinal tract Vitamin A, D, B, and iron), (3) digestion, (4) the closure of the glottis), Obesity, GERD (where in gastric  unlike breast cancer genes are not usually involved in the chemotherapeutic drugs may be less effective (hence, the acid and enzymes reaches the esophagus and with chronic development of cancer in upper gastrointestinal tract option of therapy is surgery), (5) and because liver and GERD, the condition will lead the individual to — Barrett's Screening & Diagnostic Test for Upper Gastrointestinal pancreas is connected to the stomach through the Esophagus where in the lining of the esophagus resembles Cancer duodenum, if the patient has stomach cancer, the chance the lining of the intestines due to the esophagus chronic  currently there are no routine screening recommendations for UGI cancer and the first test being performed are visualization of  temporarily numb the area), prepare suction machine, and  w/ no evidence of invasion the UGI through radiology studies oxygen  Stage II: if it already penetrated the submucosa or the muscle  Intra Test: position patient into left lateral to facilitate layer and the size of the tumor is less than 5 cm and may or Barium Swallow salivary drainage and easy access (+ comfort) may not involved the lymph nodes  fluoroscopic procedure and a x ray examination where in the  Post Test:  Stage III: if tumor is more than 5 cm and definitely an patient drinks a certain amount of radiation which serves  NPO until gag reflex return to prevent aspiration involvement of the lymph nodes as the contrast dye, this allows the visualization of the  SIMS or semi fowler's (to promote lung expansion) position  Stage IV: definite lymph nodes involvement under a large size linings of the UGI tract especially the esophagus and until the full awaken and a distant metastasis also occurs stomach (+ the duodenum and upper jejunum)  monitor signs of perforation, bleeding, pain, unusual difficulty  prior to the dray procedure the patient will drink 250 until 300 of swallowing, elevated temperature mL of barium solution at least hourly for 4 times — why?  maintain bed rest for the sedated client until alert kasi remember the mucosal lining if the GIT is smooth  lozenges, saline gargles, or oral analgesics can relieve minor making the barium solution not to be absorbed sore throat after the gag reflex returns immediately  Take Note: the last dose of the barium solution is drunk when ERCP (aka. Endoscopic Retrograde Cholangiopancreatography) the patient is already inside the x ray room (this will also Biopsy determine the abnormal movement of the esophagus  definitive diagnostic test during swallowing)  liver biopsy is removal of the liver tissue and usually dine include din sa health teaching na hindi masarap yung through the use of fine needle aspiration which permits the solution since most of the patients says na lasang examination of liver cells Staging of Liver Cancer chalk daw  because of the anatomical proximity of the liver to the lungs, some may also complain nausea upon drinking the prior insertion of the aspirating needle we have to instruct barium solution that is why it is important to remind the patient to inhale exhale and hold so that the lungs is in the patient that the process may be repeated if there the relaxed state during the insertion of the needle in order are any disruption during the drinking process to prevent trauma to lung tissue do not forget din the Consent since gagamit ng contrast  Position: supine and raise the right arm to exposed the dye sa procedure na toh insertion site then local anesthesia is introduced on the site evaluate any allergies din sa contrast dye or iodine where needle insertion is done and aseptic technique is  Pre Test: NPO post midnight (after midnight for about 6 to 8 observed  with regards to pancreas and liver they don’t have mucosal hours depending on the protocol of your institution but  some liver biopsy is guided by ultrasound (depending on the lining to stage them like the gastrointestinal tract normally it ranges to 12 hours) ligation of the tumor)  depends on the location of the tumor  Post Test: Laxative; instruct the patient to drink a lot of fluids  Common Complication: bleeding or leakage of bile which may  Stage I: tumor arise in one segment of the liver wherever the to eliminate the barium and inform the that their stools will lead to peritonitis location is turn white, monitor for obstruction  Nursing Consideration:  Stage II: if the tumor arises in the border of the segment kasi ensure that coagulation study are obtained and the it already occupies two segment of the liver or if the tumor EGD (aka. Esophagogastroduodenoscopy) values are noted and the abnormal results are is large and covers the 2 segment  visualization of the upper GIT by the use of endoscope treated before liver biopsy is performed  Stage III: if many segment are totally involved (more than 2 (esophagus, stomach, down to duodenum) first thing to do is to secure the consent segment) — 2 tumors in one segment is considered as  Pre Test: ensure consent (and let the physician explain the after the biopsy the patient is positioned in the right multiple tumors regardless of the size even if its located in procedure to the patient), NPO for 8 hours (since gastric side and pillows may also be placed under the patient the same segment juices lang dapat ang laman ng stomach), pre medications on the side of the liver to give pressure to the  Stage IV: if many segment are involved and meron ng such as atropine (in order to reduce the secretions of the injection site to prevent bleeding metastasis patient to prevent aspiration) and anxiolytics (in order to reduced the anxiety of the patient), prior to the insertion Staging of Gastrointestinal Cancer Staging of Pancreatic Cancer of flexible endoscope to prevent gag reflex and promote  typically depends on the size of the tumor and the layer of  use of TNM classification and the size is considerable easy insertion, local anesthesia is administered (using the mucosa that has been penetrated  Stage 0: if the cancer is confined and has no invasion of lidocaine spray — sprayed inside the mouth to the throat to  Stage 0 or I in situ: if the involved layer is the mucosa lining deeper tissue, no lymph nodes involvement, no metastasis and only carcinoma in situ tapos characterized by continuous dull ache in the RUQ and pain of the esophagus so there will be risk for girth and aspiration  Stage I: if cancer is confined and the tumor is less than 2 cm that radiates in the back  Nursing Consideration: soft diet for 4-8 weeks depending on but not more than 4 cm, no involvement of lymph nodes  weight loss maybe due to anorexia and weakness the doc advise; if back to normal diet, be careful from and metastasis  hematemesis since may function ang liver dito hence, anemia eating meat, cut into small slices in order to swallow; avoid  Stage II A: if cancer is confined and bigger than 4 cm, no may also occur eating 2 hours before sleeping may cause regurgitation; lymph nodes and metastasis  hepatomegaly or irregular upon palpation drink water 30 mins before eating solid food; 30-60 mins to  Stage II B: if cancer is confined and not bigger than 5 cm, no  jaundice may also occur if bile ducts are occluded or finish food and sit while eating to avoid aspirations. lymph nodes and metastasis compressed by large tumors additionally, it may also give  Stage III: if cancer is growing outside the pancreas, tumor is us white stools in return (since the bile gives our stool the more than 5 cm, with lymph nodes but no metastasis brown color)  Stage IV: if cancer metastasized regardless of the size of the  tumor may also compress the portal veins and causes the fluid tumor from the liver and intestine to accumulate in the abdomen  Take Note: the most common stage which is not easily which could lead to ascites diagnosed is the Stage I because it is manifested by DM condition kaya the patient will be treated with incorrect Signs & Symptoms of Pancreatic Cancer  Esophageal Stent: keep the block area open; retract or keep diagnosis, pancreatic cancer may only be suspected if the  depends on the tumor location small tumors /obstructions away that hinders the passage patient does not show any kinds of improvement even if  jaundice may be evident because cancer may spread to the of food into the stomach. they are compliant with the treatment of DM however, liver which causes the urine to be dark and stools to turn Indicated for small tumors or stage 1 cancer yung treatment ng DM usually takes 2 yrs kaya when white because of the compression of the tumor into the Maid of metal, plastic, or silicone. diagnosed the patient is already in stage III or IV biliary ducts (jaundice may also be associated with  Endoscopic Mucosal Resection: can be diagnostic or uncontrolled blood glucose level and impaired productions therapeutic; determines tumor location and characteristics; Signs & Symptoms of Esophageal Cancer of the pancreatic enzyme that mixes with liver enzymes performed on small tumors or polyps (less bleeding)  early stages usually do not produce physical symptoms that produces bilirubin)  once cancer has advanced, most common signs and  dull constant abdominal pain which occurs in more than 80% symptoms are: of patient and yung pain is vague upper or mid abdominal  coughing (may be due to presence of tumors in the esophagus (hindi mo siya made distinguish) which sometimes radiates which compress the laryngeal nerve) or hoarseness to the back and usually nangyayari siya after eating  weight loss due to dysphagia (95%)  pain is often progressive and severe which may require pain  painful or difficulty swallowing because of the tumor aside medication (it may be relieved through sitting or leaning from dysphagia forward)  regurgitation of undigested food specially to patient with  and if pancreatic carcinoma is already advanced weight loss is history of GERD considered as the classical sign  hematemesis or presence of black tarry so because of bleeding Week 16 | Part 2: Surgical Management of Gastrointestinal Tract Cancer Signs & Symptoms of Stomach Cancer Esophageal Cancer | Esophagectomy  dyspepsia (more or less 50% among all symptoms) usually  Not total removal of esophagus, only the affected area. After pain or discomfort in the abdomen removal there will be an end to end anastomosis  Other Types of Anastomosis:  weight loss due to anorexia  Before undergoing the procedure, need ng clearance from the Billroth I: partial gastrectomy; portion of stomach is  epigastric discomfort cardio and pulmonary doctor. removed wherein the tumor is located then  nausea and vomiting  After 5 to 7 days post-op, client will undergo barium swallow remaining portion is anastomized into the  early satiety madali silang mabusog or parang bloated sila to check if there is leakage duodenum; also called as gastroduodenostomy and persistent indigestion  Esophagus is being closed by layers starting from mucosal Billroth II: partial gastrectomy; remaining segment is  hematemesis presence of black tarry so because of bleeding linings, before incision is closed to reassure anastomosis is anastomise in the jejunum; called as successful, NGT is inserted then flushed normal saline and gastrojejunostomy Signs & Symptoms of Liver Cancer check if there is leakage.  90% of patients complain of abdominal pain = initial sign  After anastomosis, stomach is pulled because of the shortness  Liver Tumor | Hepatectomy  Anastomoses: Pancreaticojejunostomy: pancreatic juice enters jejunum to aid in digestion Hepaticojejunostomy: bile enters jejunum to aid digestion Duodenojejunostomy: restores continuity of GI tract; food passes to jejunum from stomach, preserving pylorus function  Nursing Care for NGT Decompression of Intestine: Monitor amount, color, check for leakage of JP drainage;  Liver tumors or hepatocellular carcinoma surgical resection is may be yellow to green bile and reddish if bleeding. the treatment of choice Monitor for bleeding  If the tumor is confined to one lobe of the liver, other lobes Check sugar levels to control glucose; function of function is still considered adequate. pancreas will be altered  Lobectomy: removal of lobe Goal — less than 150 or 150 - 170 is tolerable  Liver transplant is another choice but not all patients are WOF common complications: leakage of pancreatic qualified even if may available resources enzyme  Milan Criteria: developed to limit transplantation to patients Determine lipase & amylase increase which indicates who are most likely to survive and have a better outcome; damage to pancreas (advise clients to reduce eating single tumor diameter of less than 5 cm not more than 3 fatty foods) foci of tumor, each one not exceeding 3 cm.  Roux-en-y: the stomach is removed, what happens to the  Cryosurgery: cryoablation therapy; cancer cells freeze; Upper GIT | Radiation Therapy connection? Involved the creation of jejuno-jejunostomy perform percutaneously kasi sa ibabaw lang ng skin; use Brachytherapy Stomach removed wherein the proximal duodenum is extreme cold to destroy cancer cells; extreme temperature  Internal radiation stapled or closed and the distal part is the first part of is delivered by the cryoprobe using nitrogen.  Indicated for obstructive tumors particularly in the esophagus the jejunum, next part of jejunum pulled up to be Saan napupunta ang dead cancer cells? Will be  Radiation seeds will be administered via NGT and implanted connected directly to the esophagus or remaining absorbed by the body and excreted as a waste for a specific period of time part of the stomach product.  Pwede ba kumain? NAUR. Barium swallow 1 week post op to determine the Pancreatic Cancer | Whipple Procedure Pwede thru TPN or PEG effectiveness of anastomosis PEG is performed surgically; Not advised for clients with stomach cancer  Removal of the head of the pancreas where the tumor is dominant. Also removed the adjacent structures including the majority of the duodenum, duodenal papilla (pancreatic duct and common bile duct met in the duodenum to function on the flow of the enzyme to aid in Selective Internal Radiation Therapy (SIRT) digestion)  Delivered via blood vessels or hepatic artery  Gallbladder, common bile duct, portion of jejunum  Mas effective if yung tumor ay may blood vessels na or is called angiogenesis so may connection na sila sa hepatic artery  Can be used in conjunction with chemotherapy surgery and which will be visible sa MRI otherwise wala dadaaanan yung radiation catheter to deliver  Yttrium 90: most common radiation source Percutaneous Infusion  Radiation sources will be found in the client’s excreta like  Minimally invasive introduction of chemo drugs into the sweat so advisable na wag hawakan ang client tumor  If mag-use ng toilet, flush it for 2 to 3 times to assure that  Guided by ultrasound radiation sources are eliminated  Chemo drugs administered is cisplatin gel with the use of syringe  Cisplatin: platinum chemo drugs; highly emetic (nakakasuka) Need prepare ng IV anti emetic meds Take note of the -setrons Dolasetron, granisetron, ondansetron, palonosetron  nausea & vomiting, bone marrow suppression, fatigue, diarrhea, alopecia, orange urine, renal toxicity and  Colon Lumen: surface of the colon; close contact with large hepatotoxicity intestine; exposed to waste material Week 16 | Part 3: Colorectal Cancer  Month of March: Colon Cancer Awareness Upper GIT Cancers | Nursing Consideration – Radiation Therapy Anatomy Review | Colon  Take note of the adjacency of each organ in the abdomen,  divided into 3: Ascending, Descending and Transverse Colon kahit na sa isang specific area lang intended yung radiation  Ileocecal Junction: hinahanap ng surgeon & ineexpose when pwede rin ma-apektuhan yung mga kalapit na organ. performing appendectomy Ex. radiation on the small intestine may affect pelvic  Ileocecal Valve: prevents the content of large intestine from bone, bone marrow suppression may occur. Pwede going back to the small intestine magkaroon ng pancytopenia  Descending & Sigmoid Colon: where cancer cells commonly occurs Chemotherapy Drugs!  Esophagus: 5-FU (Fluorouracil), Cisplatin  Stomach: FAM (Fluorouracil, Adriamycin, & Methotrexate) / ECF (Epirubicin, Cisplatin, Fluorouracil), 5-FU, Cisplatin, Risks for Colorectal Cancer Adriamycin, Mitomycin-C, Epirubicin  Older Age: between 65 to 74; dies from this cancer is 68 years ECF usually prescribed by the doctor after surgical old treatment Recommended Age for Screening — 50 yo for  Drug Complication — methotrexate is the renal toxicity sigmoidoscopy and colonoscopy  Antidote: Leucovorin  Family History: 20% of patients  Liver: 5-FU, Mitomycin-C, Cisplatin, Doxorubicin Lynch Syndrome: most common inherited syndromes  Pancreas: 5-FU-based regimen linked with colorectal cancers Hereditary non polyposis colorectal cancer (HNPCC) & Chemoembolization! familial adenomatous polyposis (FAP) (can become  Image guided, minimally invasive technique malignant; screen by 45 years old)  Placement of embolic agent (pambara) in combination of Other rare syndromes can increase colorectal cancer risk chemo drugs into the blood vessels which feeds the tumors too  Embolic agent will impede the blood supply in the tumor and  Previous Colon Cancer or Polyps will keep the chemo drug within to kill the cancer cells bc it  History of Inflammatory Bowel Disease (often develop is deprived from blood supply dysplasia), Crohn’s Disease & Ulcerative Colitis   Diet: high fat, high protein, low fiber alters the shape of the left colon and prevents abnormalities such as tumors and lesions formation and passage of normally formed stool  Double Contrast Barium Enema: Mahogany Colored: symptom of right sided cancer of Apple core = stenosing (narrowing of colon bc of 2 colon. It results from the mixing of blood from the tumors in opposite direction) tumor with the stool and its exposure to digestive Barium + injection of air tract secretions as it progresses through the Barium is administered first then xr-ay to outline the remaining colon structure of the colon then insertion of carbon If the client is bleeding, obtain CBC and maybe explain dioxide in the same tube to further enhance the x-ray why there is anemia, easy fatigability and loss of showing a thin mucosal coating of the intestine appetite Familial Polyposis: presence of too much gastrointestinal polyps Let’s Talk About Prevention! Nursing Consideration: observe for carbon dioxide  Exercise, Change of Diet & Lifestyle toxicity using capnogram; increase fluid intake to High Fat, Protein (red meat) increases the risk flush the barium from the system; white discoloration High Fiber decreases the risk (Beans, Whole Grains, of stools for the first 2 defecation Vegetables, Fruits, Nuts, and Seeds) Assessment  change in bowel habits, blood in stool, and tenesmus Screening, Detection, Diagnosis  Characteristics of the Stool:  FOBT or Fecal Occult Blood Test: parang pregnancy test but stool ang gamit, pwede at home basta hindi macocontaminate yung stool Other term is Guaiac Test or Hemoccult Blood Test or Fit Test Prevent/Avoid Prior Testing — red meat and raw vegetables (such as radish, turnips, melon, horseradish) Avoid Medication — aspirin, iron, anticoagulants (may give false positive reading) Vitamin C & K (may give  Flexible Sigmoidoscopy (F.SIG): visualizes the lower 3rd of the false negative) Color of Stools: colon Test Should be Delayed — if menstruating and 3 days  Brown — normal due to bile Instrument Channel: serve as suction para hindi maipon afterwards and/or if bleeding hemorrhoids  Green — indicate inflammatory bowel disease or malnutrition yung water sa mismong intestine; distilled or sterile Preparation— foods and vitamins avoided 3 days before or eating green vegetables water while medications are avoided 7 days before  Tan — indigestive fats which causes congestion in the liver & Should be shiny  Digital Rectal Examination (DRE): Insertion of gloved finger gallbladder; not normal and considered as sign of into the rectum to check if there is a presence of abnormal gallbladder disease (gallstones or blockage or liver injury) protrusion, polyps or tumors  Gray / White — pancreatic or liver injury; absence of bile Digital = fingers  Red — high amount of red foods; effect of certain  Visualization of the Lower GIT: medications; hemorrhoids; diverticulitis; lower GI bleeding Proctosigmoidoscopy — visualize rectum up to sigmoid  Black — internal bleeding upper GI colon; jack knife / knee chest / lithotomy position; ask Black, Sarry Stools: indicative of blood from the upper surgeon their preferred position b4 surgery. GI tract, which has been in the GI tract long enough Colonoscopy — detect tumors as far as transverse to be completely digested colon; obtain consent form; NPO night b4; enema Loose, Frothy Stool: indicative of steatorrhea or fat in ordered & done; stool. Large amounts of fat are expelled in the stool Barium Enema: barium will coat the lining of the colon as a result of a variety of malabsorption syndrome up to the desired level of colon and then undergo  Flat, Ribbon Shaped: consistent with a tumor, which xray to reveal structures observed for any signs of   In Situ: cancer has formed, but not yet growing inside colon or  Laparoscopic Colectomy: done if there is a larger tumor found rectum in the segment of the colon; removal; minimal invasive bc  Local:cancer now growing in colon or rectum walls; only 4 small incisions are needed unaffected nearby tissue  Colon Resection with Anastomosis: if larger portion of the 90% survival rate;40% due to low screening rate colon is involved and nearby tissues are removed; proximal  Regional: growth beyond the colon of rectum walls and into and distal end of the intestine are anastomized tissue or lymph nodes Barium enema is required to check if there is any  Distant: cancer has spread to other parts of the body such as leakage  Crohn’s Disease: patchy erythema, aphthous ulcers, linear liver or lungs  Colon Resection: Abdominoperineal Resection (APR): if lower ulcers portion GIt particularly the anal sphincter, rectum & distal TNM Staging System: colon wherein the client is unable to defecate thereby  Stage I: inner lining of the colon or mucosal lining resulting in permanent colostomy; 2 incisions are done,  Stage II: imbedded into the colon wall or muscle layer one on the distal portion then another one on the  Stage III: penetrating through the colon wall, muscle layer, & perineum; cleanest to dirtiest; completely remove the serosa involving the lymph nodes distal colon, rectum, and anal sphincter  Stage IV: distant metastasis  Colostomy: creation of opening; arises where tumor is found and depending on the location of what is being resected Complications Ascending colostomy  Obstruction: bc of the tumor, depending on the size and to Transverse colostomy assess the obstruction, we determine the frequency of Cecostomy defecation, characteristics, and consistency of the stool Ileostomy  Hemorrhage: tumor has signs of bleeding, need to evaluate Sigmoid colostomy the melena  Peritonitis: indicate penetration of the tumor outside the colon which may cause leakage of intestinal content outside the peritoneum; inflammation of the peritoneum wherein the hallmark characteristic is board-like abdomen  Sepsis: untreated peritonitis Summary of What Diseases Can Be Diagnosed in Colonoscopy How to Treat Colon Cancer?  Diverticulitis  Systemic Therapies: treat the whole body (chemotherapy &  Appendicitis immunotherapy)  Ulcerative colitis  Local Therapies: treat the primary site of the cancer only  Adhesions (surgery & radiation therapy)  Flat polyp / lesion  Endoscopic Polypectomy: removal of polyps; done during  Polyp sigmoidoscopy & colonoscopy  Crohn’s disease  Cancer Other Tests | Screening, Detection, & Diagnosis  Laboratory: CEA, CA 19-9, CBC  To Check for Possible Metastasis: chest x-ray, abdominal CT Pre Operative Care scan, Liver function tests (AST/ALT)  Bowel Preparation: diet (NPO), post-operative health teachings and stoma and colostomy care, enema, & Stages of Colon Cancer abdominal PE (NGT to prevent distention)  Polyp: most colon cancers develop from these noncancerous  Monitor urine output and fluid & electrolytes growth  Antibiotics 1 day prior ro surgery Post Operative Care  you may also observe urostomy appliance thus it is not for  This is a type of skin barrier that serves a attachment device  Monitor for complications (signs of bleeding, pain) colostomy because it is for the drainage of the urine after for pouches  Return of peristalsis bladder surgery  Adhered over the skin but before it is should be placed the  Wound (splinting)(support abdomen when coughing to  Colostomy Bags w/ Close Pouch: nurse measures the diameter of the stoma for this prevent trauma) Close & Pouch appliance to fit using this guide  Skin and stoma care (Nystatin to prevent formation of molds, Drainable with Tail Tip  Once measured, directly it will be attached to the skin (the fungus, & yeast) Drainable Pouch with Clipless Closure stoma and the needle) it should not be lose because the  Early ambulation (to shorten time of recovery and promotes  Urostomy Pouch: function of these pouches is just 3-6 days pouch might fall and not too tight because it might irritate normal functioning of bowel) post op the stoma, it should be just right  Nutritional health teaching (limit foods that causes gas  Measure the stoma opening, pouch opening for about 0.3 cm formation; high fiber diet) larger than the stomal opening  Apply adhesive surface over the stoma and press for 30 Week 16 | Part 4: Management of Colorectal Cancer seconds Colostomy Care  There are ostomy appliances wherein ang skin barrier is  fecal material in colostomy are irritating in peristoma skin or already attached to the pouch (nakaready na) the skin around the stoma because of that enzyme present  Skin barrier is separate where only the pouch can be remove in the gastric juices particularly in ileostomy wherein Ostomy Wraps and the skin barrier stays attached to the skin, tatanggalin gastric juices are much more that colostomy because it is in  promotes a more comfortable way to carry ostomy appliance nalang byung pouch pagddrain na yung waster materials the small intestine habang ang pagkain ay nagttravel sa especially for women whose more concerns about their  The stoma should be measured first so that the skin barrier colon, nababawasan din yung enzymes and to protect body image should be attached over the skin is fit peristomal skin colostomy bag appliance is indicated  When is the best time for skincare? — after shower, you can  appliance of colic stool protects the skin and odor from the wash the peristomal with soap and water but cover the waste materials skin of the stoma while doing that in order to avoid stoma  appliance consists of skin barrier and a pouch irritation  Urostomy Appliance ng skin barrier is already attached to the  Washing the peristomal area: pouch and other option is that the skin barrier is separate Lightly pat dry and do not rub (never rub because hard where only the pouch can be remove and the skin barrier rubbing might cause bleeding of the stoma) stays attached to the skin (tatanggalin na lang yung pouch Once peristomal area is dry, light dust the peristomal pag papalitan na ng bago) area with nystatin powder that would prevent fungal  these pouches can be closed or drainable because may infections feature sa ilalim ng pouch for drainage or the waste  Draining the pouch is best in sitting position (Sit and aim the materials cleans before returning to the barrier (so usually drainage part of the colostomy on the bowl and empty the a drainable pouch has a clip to keep it closed when pouch) connected to the stoma)  Take Note: the best time to empty the bag is —  Close pouches without clip is indicated with patients with  ⅓ to ¼ full (brunner and suddarth's) regular stoma, discharge like sigmoid colostomy  ½ to ⅓ (kozier) because we do not want the pouch to reach  since the waste material that comes out is already formed, its full capacity so in that particular parameters, we can remember that consistency of the stools differ depending drain out the pouch on the location of the colon Ascending Colon: has more soft consistency stool Ostomy Management  the colostomy bag above na may design ay ginagamit natin Transverse Colon: has mushy consistency  Ostomy: opening for the GIT, GUT, respiratory tract onto the for children Descending Colon: stool is formed skin  Sigmoid is already formed because that is how each areas of colon absorb water from the remaining waste materials so Characteristics of Stool | According to Anatomic Site if you have ascending colostomy expect more fluid  Ileostomy: opening in the abdomen of the ileum of the stall drainage from a transverse colostomy drainage in the intestine thus, it cannot be regulated because colostomy bag  Liquid stool   Constant drainage (minimal)  When to Change the Appliance — Avoid Times: Radiation Therapy  Cannot be regulated close to meals or immediately after meals  used alone or in combination with surgery or chemotherapy  (+) digestive enzymes (can be irritating so tell the client to visiting hours (because colostomy odor and stools may (can be internal or external beam radiation therapy or keep their peristomal skin to be dry always and keep reduce appetite or embarrassed the client) EBRT) constant care) damaging the skin Odor is MINIMAL (fewer after taking meds that stimulate bowel movements  Neoadjuvant (given to shrink the tumor prior surgery so that bacteria) Take Note: The best time to change the pouch is when the smaller segment of colon will just be removed) or  Ascending Colostomy: the drainage is lightly to occur so the best time is first adjuvant (given after surgery to completely destroy the Liquid stool thing in the morning or 2 hours after meals when the cancer but the risk of recurrent is still there) purposes Other attributes same with ileostomy bowel is least active Odor is a problem requiring control because absorption  before the removal do not forget to perform hand hygiene Radiation Therapy Method EBRT (common method used) of water starts in this part of the colon so proper and to observe infection prevention procedure and clean  Client is positioned in supine and the beam is focused colostomy appliance of and proper stoma care gloves will do depending on the location of the tumor so one of the  Transverse Colostomy  Position: Sitting, Lying, Standing (bed or bathroom) — nursing considerations is to remind our radiologic MUSHY drainage facilitates smoother pouch application (to avoid wrinkles in technician about the exposure of reproductive system of Malodorous the area) the male clients Usually no control (continuous)  Remove the Skin Barrier: peel the skin from the barrier slowly  Normally, protective devices are put in place over the  Descending Colostomy beginning from the top working downward holding the skin reproductive system of the client in order to prevent the Increasingly solid fecal drainage taut because it minimizes discomfort and avoid abrasion of risk of affecting the spermatogenesis of the client  Sigmoidostomy: the skin  Female clients with colorectal cancer we usually we Feces is normal and has formed consistency  Clean & Dry the Stoma: use warm water + mild soap discourage them to be pregnant because immediately your Frequency can be regulated this is why we can use close (optional because Sometimes not advisable to be use since radio therapy will be one of the option for treatment and pouch type in this type of colostomy it is irritating for the skin), wash cloth (make sure to check  Radiotherapy will occur in the abdomen, we have to take note the protocols) then pat dry for the possible side effect of the radiation directly to the Changing a Bowel Diversion Ostomy Appliance Assessment  When to Drain the Pouch: 1/3 to½ full and before sexual patient  Soma Color: intercourse  Side Effects: take note that this is only possibilities because of red/pinkish (same with the color of our mucosa lining)  What to Avoid? — Gas forming foods the nearness of the radiation to these organs and slightly moist  Apple, Broccoli, Cabbage, Eggplant, Melon, Milk, Onions Diarrhea (radiotherapy can alter bowel movement of the danger! intestine, fertility issues because radiation is near in very pale, dark colored, dusky, bluish, purplish (danger Ostomy Irrigation the reproductive system as well signs) this is impaired circulation so we have to notify  is similar to enema (form of stoma management use for BM (bm suppression because the nearness of the the surgeon stat! clients who have sigmoid or descending colostomy radiation to pelvic bones so we have to take note if  Size & Shape: slightly protruding from the abdomen  Purpose: distend the bowel sufficiently to stimulate peristalsis pancytopenia New Stoma — swelling is normal (2- 3-6 weeks) and If it which stimulates evacuation swell beyond 6 weeks this may indicate blockage of  Amount: Brachytherapy 1-192 the stoma For most clients is 300 to 500 mL of tap water can  High dose rate type of brachytherapy is placed in the tumor Danger! — Failure of swelling to cease may indicate a already stimulate the evacuation following resection of colorectal cancer such as adjuvant problem 500 to 1000 mL lukewarm NSS may be needed because This catheter will deliver the radiation is often placed to  Stoma Bleeding: slight bleeding when touched: NORMAL colostomy is known stinker and the fluid tends to a silicon flap that can be cut according to the size of Danger! — other bleeding should be reported so we return to its instilled yung tipong wala na the tumor have to be careful in caring of the stoma especially if magcocontrol kaya lumalabas na agad This flap will be placed in the tumor and other radiation client has a problem with bleeding control  Frequency: irrigation is done once a day and same time each source is the iridium 1-192 which will pass through  Peristomal Skin Status: day the catheter to deliver the radiation directly to the  Transient (temporary weakness) redness after removal of  (+) Cramping (temporarily stop) tumor appliance: NORMAL too fats, introduction of air Often place to a silicon flap that can be cut to confirm  Danger! — redness and irritation (5-13 cm surrounding the cloud solution (kaya nagkakaroon ng stimulation) the tumor bed stoma) should be noted Burning sensation under the skin Flap is placed in the operative field and appropriate may mean skin breakdown shielding  Stays 1 cm intervals to deliver radiation  Difference between folfox4 and 6 is that 6 emits the bolosis the urethra after the first day Brachytherapy y90  So the benefit there is that patient cannot have to return to  some doctors prefer SIRT (Selective Internal Radiation the cancer center between days of chemotherapy they just Therapy) have to go in the during first day to start the chemotherapy Also used in liver cancer / metastasis and comeback in the 3rd day to gets disconnected to the Radiation source is injected into the artery that supplies chemotherapy the blood in the tumor wheein it can be directly kill  Folfox6 have a acceptable profile in terms of both efficacy and the cells safety in previously treated colorectal cancer pt Blood supply can be seen in enhance type of imaging  Metastatic colorectal cancer combination of leucovorin, system such as MRI fluorouracil with oxaliplatin which is folfox4 is a standard Radiation Source: Yttrium/ Y90 first line regimen 90 is so called radio embolization commonly done na The cumulative neuro toxicity of oxaliplatin often required   prostate gland surrounds the male urethra so that means that ginagamit sa patient with liver cancer / metastasis therapy to stop in patient who are still responding ant enlargement if the prostate could lead to abnormal therefore you have to WOF neutropenia, diarrhea and urinary function of the male client EBRT grade 3 neuropathy  remember for colostomy bag and will undergo radiation  Metastasis: Let’s Talk About Androgen! therapy, additional care is performed FOLFOX regimen  the cause of prostate cancer is still unknown however some  Frequency & Length (because they have exposed stoma their FOLFIRI (leucovorin calcium (calcium folinate), 5- evidence has shown that this is cause by a problem in male time in radiotherapy is reduced to prevent longer exposure fluorouracil, and irinotecan) hormone particularly prostate cancer is an androgen to radiation but they will have more days added because Caplri (Xeliri) capecitabine, irinotecan dependent carcinoma (katulad ng breast cancer na time is reduced compare to those client without colostomy) IFL (Irinotecan, 5-FU, Leucovorin) considered as estrogen dependent carcinoma)  Skin Markings & Skin Care (because stoma is exposed) Immunotherapy combined with chemotherapy is also  masculinizing effect such as giving males more muscle mass Irritation of surroundings tissue are possible because of being used such as combining immuno drugs than females radiotherapy effect (Bevacizumab, cetuximab, irinotecan, oxaliplatin, 5-  this is required by the sertoli cells to the support sperm  Possible Side Effects: depends on the location and adjacency FU and capecitabine) production and nourishment of the developing sperm cells to the organs  Finally the targeted agent, bevacizumab, and cetuximab) are through spermatogenesis also available and we use this with combination with  in CNS: implicated in the regulation of human aggression and Chemotherapy irinotecan or oxaliplatin, 5-FU or capecitabine) libido that is why males are more aggressive than female  Drugs that are now available include your 5-fluorouracil, As for the studies, the bevacizumab with the combination of  Predisposing Factors:  capecitabine, oxaliplatin folfox has been shown improve survival likewise, cetuximab Genetics — especially if it's their immediate family and  Adjuvant: FOLFOX-4 (because of the name bulimic acid came specifically with patient’s tumor who did not harbor KRAS if there are more than first degree relatives affected from fol, F if from fluorouracil and oc is from oxaliplatin) or kras mutation can be very helpful and can improve Hormones — because this is a androgen dependent Every 2 weeks for 6 months Central venous catheter survival in metastatic disease carcinoma so if merong alteration sa androgen  5-FU and leucovorin (bulimic acid which may use IV in order  So in metastatic colorectal cancer in combination of metabolites level to augment the effect 5-FU) leucovorin with fluorouracil with oxaliplatin or folfox4 is Age — 65 older Leucovorin is not chemo drugs the standard first line regimen Increase Fat Intake / Obesity — because it is caused by Usually sabay na binibigay to pag fluorouracil is imbalanced lifestyle + it will also affect the function of prescribed Week 16 | Part 5: Genitourinary Cancer the prostate gland and can alter cell proliferation  Immunotherapy: Bevacizumab, Cetuximab, & Panitumumab Anatomy Review | Prostate Environment — exposure to chemicals, radiation and  only found among males and it produces seminal fluid which dietary intake is responsible in the nourishment and transport the sperm  prostate gland is located slightly in the back and below the Illustration of an Increasing Prostate Gland urinary bladder and in front of the rectum  advanced prostate carcinoma with evidence of invasion of the  the prostate contains a duct that opens into the prostatic urinary bladder portion of the urethra and secretes the alkaline portion of  invasion of the bladder can be an obvious metastasis due to the seminal fluid, the duct is where semen is carried into prostate anatomical proximity to the urinary bladder kaya   nag kakaroon ng invasion where in the urinary function of the Diagnostic Test male will also be affected  early diagnosis will most likely give a chance of curability  Common: combination of Prostate Specific Antigen (PSA) & Digital Rectal Examination (DRE)  Take Note: elevated PSA is not diagnostic of prostate cancer it is only sensitive but not specific for cancer cells because other than cancer cells the elevation of PSA may be due to number of conditions such as BPH, acute urinary retention and acute prostatitis  DRE is also used to screen for prostate cancer and it is recommended annually for every men older than 50 y/o and 45 y/o in men naman na high risk if may first degree relatives sila na may prostate cancer  DRE is performed by a skilled examiner usually by a urologist with a use of lubricated gloved finger, the prostate gland is palpated through the rectun assess the size, symmetry, shape, and consistency of the prostate gland but it is only the lateral and posterior Signs & Symptoms of Prostate Cancer areas of the prostate that can be palpated and any  may not be evident in early stages kasi it rarely shows change detected upon palpation may represent symptoms and nagkakaroon lang ng manifestations kapag inflammatory process, infarction or presence of malaki na ang tumor tumor  Tumor Grading System: Gleason's Pattern Scale  Perineal & Rectal Discomfort: because of the prostate proximity to the area  if the cancer is large enough to impede to the bladder neck, there will be s/sx of urinary obstruction and there may be  1 non aggressive and 5 very aggressive changes in the urinary flow (patient may complain of  Grade 6: tumor well differentiated less aggressive and likely difficulty and frequency of urination and urinary retention + to grow more slowly and currently almost all male patients the urgency to urinate but by the time that they will urinate has gleason score of 6 and above there is no urine output kaya need nila iforce out ang urine)  Grade 7: moderately differentiated, moderately aggressive,  decrease in the force of the urinary stream which is likely to grow but may not spread quickly characterized by dribbling urine (parang tulo tulo lang  Grade 8 to 10: undifferentiated and more aggressive cancer yung urine) and likely to grow faster and spread  burning sensation when urinating  Take Note: DRE and PSA important screening procedure  nocturia may be present to older adult patient due to because abnormal DRE and elevated PSA may raise increasing site of the prostate (pero if bata pa naman like suspicion of prostate cancer hindi pa sila belong sa older adult yung nocturia can be a  determines how aggressive the prostate tumor is sign of significant prostate enlargement)  the tumor cells from the biopsy is look under the microscope Biopsy  hematuria is the late sign that may also occur when the and evaluated by the pathologist, the pathologist assign  Take Note: DRE and PSA important screening procedure cancer already invades the urethra and/or the bladder number in the cells being evaluated based on how because abnormal DRE and elevated PSA may raise  blood in the semen and painful ejaculation abnormal they appear and the scoring system assign grade suspicion of prostate cancerhowever, a diagnosis of cancer  erectile dysfunction is also common I to V to the most predominant pattern, secondary grade requires confirmation with prostate biopsy since  and because of the proximity of the prostate gland to the another I to V to the secondary predominant pattern of the confirmatory test sya bone the patient may complain back ache and hip pain prostate gland  3 Approaches of Obtaining Tissue from the Prostate:  anorexia, weight loss and weakness  top 2 predominant pattern ang hahanapin tapos par amag Transrectal is the most common biopsy approach where  swollen limbs come up with the score the number of 2 patterns will be the biopsy needle is introduced to the prostate gland added together via the rectum  Transperineal in which incision an is made in the  advised the patient to decrease activity for the first 24 hours perineum which is between the scrotum and rectum after the TURP and the biopsy needle is introduced in this region  avoid straining in bowel movements (needed toh if the doctor is suspicious of prostate  increase fiber in diet and expect laxatives to be prescribed cancer in front of the prostate gland or if the patient and administered has previous rectal surgery where in transrectal  Complications: approach cannot be an option) Hemorrhage that is why the patient is placed under Transurethral is the least common approach kung saan cystoclysis which is aside from pre ting spasms we the biopsy is performed by inserting the needle into can observe if there are still any signs of bleeding the prostate gland from the urethra during Urinary Continence kaya use kegel exercises cystoscopy Infection  Take Note: according to evidences, prostate biopsy only has DVT (to prevent thrombosis formation apply 80% of diagnosing prostate cancers and the remaining 20% compression stockings and a low dose of heparin may is diagnoses especially if it small tumor prevent blood clot formation + discouraged the  Risks Include: patient to sit for prolonged period of time and Difficulty Urinating encouraged them to perform ROM exercises) General Treatment of Prostate Cancer Rectal Bleeding may also be present because it was  Early Detection: “expectant management” or watchful used as an access waiting where in we wait until the cancer is causing Prostatectomy Infection since it created a path for microorganisms to  common method to treat prostate cancer symptoms — conservative management (low grade enter the prostate gland from the rectum where the disease 70 y/o and above; life expectancy < 10 yrs) fecal material passes  initiate the treatment when the patient become symptomatic Nephrogenic Systemic Fibrosis  Advanced Stages: Hormonal Manipulation Swelling may occur for 2 to 3 days  Bilateral Orchiectomy — involves the removal of both  What to Expect During a Prostate Biopsy: testecles, lie on table with knees to chest local anesthetic and nerve plexus block given for Treatment Options | Surgery Transurethral Penetration of the numbung Prostate ultrasound probe place in rectum for prostate imaging needle attached to probe collects biopsy sample Stages of Prostate Cancer  TNM Staging System  Grade I: less than 2 cm tumor arises within the prostate with no evidence of metastasis  Grade II: tumor less than 5 cm is present on both lobes of the prostate where urethra divides the prostate into 2  includes complete removal of the prostate gland with lymph  Grade III: tumor penetrated beyond the prostate gland and node sampling the lymph node is affected as well as the seminal vesicles  also used for BPH patients, in prostate cancer the tumor is  this may also be performed na kasama ang lymph nodes  Grade IV: tumor spreads to other organs such as bones and removed if it is small enough  this is a nerve sparing procedure pelvis  continuous bladder irrigation and cystoclysis is important  Retropubic: this incision may have less blood loss but it is not after TURP to prevent spasms and blood clot formation an intended approach for lymph nodes removal which is caused by bleeding brought about by the removal the tumor Cryotherapy  close observation of drainage system is necessary because if  involves direct application of ice to the prostate gland via there is an increase in bladder distention, it could cause percutaneous inserted cryogenic probes pain and bleeding  introduces argon gas that freezes the prostate gland and  for complaints of pain analgesic may be prescribed destroys cancer cells   the cryogenic probes is introduced through the guide of Chemotherapy ultrasound and continuous temperature monitoring is done  Taxanes: most common chemotherapeutic drugs used— can  can be performed under spinal anesthesia rather than general slow cancer growth as well as reducing the symptoms of anesthesia therefore it is more offered in men who are not prostate cancer candidate for surgery (since old age cannot handle general SE — peripheral neuropathy that is why nursing anesthesia) management consist of constant assessment and  treatment is done in less than a day and it may have a fewer continuous monitoring of the neurologic status of the side effects patient particularly the lower extremities of the  effective for high, intermediate, and low grade prostate patient during docetaxel