Epigastric Pain and Weight Loss by Dr.

Luqman Rhman

This Lesson discusses the approach to patients with chronic epigastric

pain and weight loss with a focus on Esophageal-Gastric Cancers.

Last modified by Sariya Dler on Tuesday, 19 May 2020, 10:27 PM

This document was downloaded on Sunday, 25 April 2021, 6:34 AM
Introduction
Pain

•Challenging complaint for both primary care and specialist clinicians

•Abdominal pain is often a nonspecific complaint that presents with other symptoms.

Clinicians are responsible for trying to determine which patients can be safely observed or treated
symptomatically and which require further investigation or specialist referral. This task is
complicated by the fact that abdominal pain is often a nonspecific complaint that presents with
other symptoms
Causes of epigastric pain
Epigastric Pain can be acute or chronic and can have many causes.

The following table lists a number of common causes for both acute and chronic epigastric pain.
Evaluation of Epigastric Pain-1

EVALUATION

Abdominal pain (which include epigastric pain) is a common problem. Most patients have a
benign and/or self-limited etiology, and the initial goal of the evaluation is to identify those patients
with a serious etiology that may require urgent intervention. A history and focused physical
examination will lead to a differential diagnosis of abdominal pain, which will then inform further
evaluation with laboratory evaluation and/or imaging.

History — The history of a patient with abdominal pain includes determining whether the pain
is acute or chronic and a detailed description of the pain and associated symptoms, which should
be interpreted with other aspects of the medical history.

The overall sensitivity and specificity of the history and physical examination in diagnosing the
different causes of abdominal pain is poor, particularly for benign conditions. Fortunately, studies of
the accuracy of history and physical examination for the more serious causes of abdominal pain
(eg, acute appendicitis), alone or in combination with focused investigations, have yielded better
results.

Acute versus chronic — There is no strict time period that will classify the differential diagnosis
unfailingly. A clinical judgment must be made that considers whether this is an accelerating
process, one that has reached a plateau, or one that is longstanding but intermittent. Patients with
chronic abdominal pain may present with an acute exacerbation of a chronic problem or a new and
unrelated problem.

Pain of less than a few days’ duration that has worsened progressively until the time of
presentation is clearly "acute." Pain that has remained unchanged for months or years can be
safely classified as chronic. Pain that does not clearly fit either category might be called subacute
and requires consideration of a broader differential than acute and chronic pain.

Description — Pain should be characterized according to location, chronology, severity,

aggravating and alleviating factors, and associated symptoms. It is also important to note if the
patient has recurring episodes of similar pain as this may narrow the differential.
Evaluation of Epigastric Pain-2

Epigastric pain:

Patients with epigastric pain and cardiac risk factors and/or other symptoms concerning for angina
(eg, shortness of breath, exertional symptoms) should have appropriate cardiac evaluation.

Other patients with epigastric pain should be evaluated for pancreatitis as well as gastric etiologies.
Patients should have the following laboratory studies:

?Complete blood count with differential

?Electrolytes, BUN, creatinine, and glucose

?Aminotransferases, alkaline phosphatase, and bilirubin

?Lipase and/or amylase

If there is concern for hepatobiliary pain, patients should have an abdominal ultrasound for
evaluation. Patients with concern for other etiologies should have appropriate evaluation (eg, if
concern for peptic ulcer disease, endoscopy may be indicated)

Pain limited to the epigastrium, which may be associated with bloating, abdominal fullness,
heartburn, or nausea can be classified as dyspepsia.
Weight Loss

Weight Loss
•Intentional VS Unintentional

•Unintentional: an important sign

A- Malignancies

B-
Chronic infection/Inflammatory condition

C–
Metabolic/Endocrine

D-
Psychiatric

How much is clinically important weight loss?

If someone has lost 5 kg in the past 6 months (unintentional),

his current weight is 60 kg.

Is his weight loss clinically important?

•(4.5 kg) or >5% of one’s body weight

over a period of 6–12 months.

•People with no known cause of weight loss generally have a better prognosis than
do those with known causes, particularly when the source is neoplastic.

• Significant
weight loss is associated with increased
mortality
Initial workup

Initial workup

Initial workup is focused on differentiating benign functional illness from organic pathology.
Features that suggest organic illness include weight loss, fever, hypovolemia, electrolyte
abnormalities, symptoms or signs of gastrointestinal blood loss, anemia, or signs of malnutrition.
Laboratory studies should be normal in patients with functional abdominal pain.

The following laboratory measurements should be performed in most patients with chronic
abdominal pain:

?Complete blood count with differential

?Electrolytes, blood urea nitrogen (BUN), creatinine, and glucose

?Calcium

?Aminotransferases, alkaline phosphatase, and bilirubin

?Lipase and/or amylase

?Serum iron, total iron binding capacity, and ferritin

?Anti-tissue transglutaminase

Further evaluation with imaging will depend on the differential diagnosis based on the history,
physical, and laboratory studies
Question-1
Regarding Epigastric pain:

A. Usually associated with altered bowel habits

B. Very Uncommon

C. It could be of a non-organic cause.

D. Indicates serious pathologies such as gastric cancer

E. acute or chronic, it has the same workup plan.

C. It could be of a non-organic cause

Score: 1

A. Usually associated with altered bowel habits

Score: 0

B. Very Uncommon

Score: 0

D. Indicates serious pathologies such as gastric cancer

Score: 0

E. acute or chronic, it has the same workup plan.

Score: 0
Question-2
In Evaluating Epigastric Pain and weight loss:

A. Weight loss is only significant when it is more than 10 % of body weight over 6 months.

B. The presence of Iron deficiency anemia indicates malignancy.

C. The absence of family history of malignancy excludes malignant causes.

D. Age is not relevant to the cause.

E. History and physical examination, especially when combined with investigations, have a very
high sensitivity and specificity in identifying serious causes.

E. History and physical examination, especially when combined with investigations, have a very
high sensitivity and specificity in identifying serious causes.

Score: 1

B. The presence of Iron deficiency anemia indicates malignancy.

Score: 0

C. The absence of family history of malignancy excludes malignant causes.

Score: 0

A. Weight loss is only significant when it is more than 10 % of body weight over 6 months.

Score: 0

D. Age is not relevant to the cause.

Score: 0
Esophageal Cancer

Esophageal Cancer: Introduction

The incidence of esophageal

cancer is on the rise with over 12,000 Americans
developing this disease each year. Variations in the incidence of esophageal cancer are seen with
age, sex, and race. Advances in medical and surgical therapy have led to improvement in the
survival rates but continued improvement in survival is dependent
on a better understanding of the relationship between environmental factors and the disease itself.

The incidence of esophageal cancer fluctuates

dramatically throughout various regions of the world and has the largest
variability of any known malignancy. High rates are found in people living in
northeast China to north central Asia, Afghanistan and northern Iran. Other high-risk
groups include the white population in parts of South Africa and areas of Finland,
Iceland, and France. In the United States, trends demonstrate that black men have
a fourfold greater incidence than white men for squamous cell esophageal cancer
with significant variation in locale, nutritional status, socioeconomic status,
and alcohol and cigarette use.
Esophageal Cancer-Anatomy/Histology

Anatomy
The esophagus serves as a conduit between the pharynx and the stomach. The body of the
esophagus
is approximately 18–25 cm long extending
from the upper
esophageal sphincter to the lower esophageal sphincter. The length of the esophagus correlates
with an individual's height and it is usually longer in men than in
women

Histology

Esophageal cancer can be classified according

to the site of origin.
The malignancy may originate in the squamous cells, or in the columnar cells that line the
esophageal lumen. Squamous
cell carcinoma may occur throughout the length of the
esophagus, whereas adenocarcinoma
generally occurs just above the esophagogastric
junction.
 Adenocarcinoma
has risen sevenfold male-to-female ratio of 6:1

Adenocarcinomas
behave clinically like
adenocarcinomas, although they
are not associated with H. pylori infections.
gastric

•Squamous cell carcinomas and adenocarcinomas cannot be distinguished radiographically or endoscopically

Esophageal cancers can occur at any part of the esophagus with the following percentage:

•About 5% in the upper third

•20% in the middle third,

•75% in the lower third.

Esophageal Cancer-Clinical Presentation

Clinical Presentation:

Early stage
esophageal cancer may be totally asymptomatic or may present
with mild nonspecific symptoms such as heartburn, atypical chest pain, or dyspepsia. Alternatively,
patients may present
with symptoms such as occult blood in the
stool or iron deficiency
anemia. Patients may report mild or intermittent dysphagia, odynophagia, or a foreign body
sensation. These symptoms
generally warrant diagnostic
evaluation, including an esophagogastroduodenoscopy (EGD) (upper endoscopy),
including diagnostic mucosal biopsy.

Some early cancers are diagnosed during routine upper endoscopic surveillance
for Barrett’s
esophagus.

The symptoms
of esophageal cancer generally progress
rapidly. Symptoms of advanced esophageal carcinoma become apparent
with tumor growth.
An initial inability to swallow
solids is followed by difficulty in swallowing ground food and finally liquids.
Progressive dysphagia
is the most common complaint
in most patients (90%) with greater than 50% luminal
occlusion or where luminal diameter is less than 13 mm.

Weight loss
and anorexia are often present in patients
with more advanced disease (due to inadequate intake of food secondary to dysphagia, or to a
nonspecific effect of
the cancer), predisposing the patient to nutritional
deficits. Odynophagia occurs in about one half of the patients. Esophageal obstruction may cause
aspiration of food and pneumonia. Tumor extension to the pericardium or mediastinum may cause
retrosternal or back pain, as well as abscess formation.

Hoarseness is usually
associated with recurrent laryngeal
nerve paralysis. Hiccups
may occur due to mediastinal and/or diaphragmatic involvement of the tumor. Anemia and/or
gastrointestinal bleeding and weakness
may be present if the tumor is ulcerated and
friable. Incessant cough and pneumonia
should alert the clinician to the possibility of a tracheo- or bronchio-esophageal fistula resulting
from tumor invasion of the nearby airways.
Esophageal Cancer-Aetiology
Esophageal Cancer-Diganosis
Diagnosis

Diagnostic evaluation of the patient with suspected esophageal carcinoma has a two-fold purpose. First, it confirms the diagnosis through the use of radiography and/or endoscopy with biopsy and cytology. Second, diagnostic evaluation determines the disease stage for the initiation of appropriate therapeutic measures.

Endoscopy

Endoscopy with biopsy is the primary method for diagnosing esophageal cancer.

The combination of endoscopic biopsy and brush cytology has the highest accuracy rate, close to
100%, in obtaining a histological diagnosis of esophageal cancer.

Noninvasive Diagnosis

Barium contrast radiography is one of the diagnostic tests for the evaluation of dysphagia and the
associated symptoms of esophageal cancer. Although endoscopy is considerably more sensitive for the detection of esophageal cancer, double-contrast barium esophagrams can detect early esophageal carcinomas.

The diagnostic accuracy of the double-contrast barium esophagram is 70%. This radiological technique is capable of documenting stricture length, diameter, location, and contour.

Endoscopic ultrasonography (EUS):

EUS is a useful tool for the diagnosis of esophageal cancer. It is a highly technical, low-risk,
diagnostic procedure that utilizes ultrasound to evaluate and diagnose digestive tract disorders. EUS allows imaging at close proximity and may detect subtle mucosal changes in the patient in whom other tests are nondiagnostic.

EUS may be helpful in directing endoscopic biopsy toward areas of endosonographic abnormalities
in patients with Barrett's esophagus and high-grade dysplasia.
Question-3
Risk Factors for Esophageal Cancer:

A. H. Pylori is the most known important risk factor.

B. Not related to geographical distribution.

C. Eradication of the Epstein Bar virus significantly reduced the incidence of esophageal cancer.

D. Smoking is a very significant risk factor.

E. Alcohol drinking is a risk factor but only when combined with cigarette smoking.

D. Smoking is a very significant risk factor.

Score: 1

A. H. Pylori is the most known important risk factor.

Score: 0

B. Not related to geographical distribution.

Score: 0

C. Eradication of the Epstein Bar virus significantly reduced the incidence of esophageal cancer.

Score: 0

E. Alcohol drinking is a risk factor but only when combined with cigarette smoking.

Score: 0
Question

Risk factors for esophageal cancer include all of the following, except:

A. Gastroesophageal reflux disease

B. Barrett’s esophagus

C. Achalasia

D. Cigarette smoking

E. Aspirin use

E. Aspirin use

Score: 1

A. Gastroesophageal reflux disease

Score: 0

B. Barrett’s esophagus

Score: 0

C. Achalasia

Score: 0

D. Cigarette smoking

Score: 0
Gastric Cancer- Introduction

Gastric Cancer- Introduction

The overall incidence of gastric cancer in the United States has rapidly declined over the past 50
years. Gastric cancer is now the 13th most common cause of cancer mortality in the United States,
with an estimated 12,100 deaths in 2003.1 However, in developing countries, the incidence of
gastric cancer is much higher and is second only to lung cancer in rates of mortality.

The typical patient with gastric cancer is male (male-to-female ratio, 1.7:1) and between 40 and 70
years of age (mean age, 65 years). Blacks are twice as likely as whites to have gastric carcinoma.
Gastric Cancer-Aetiology

Etiology

Many risk factors have been associated with the development of gastric cancer, and the
pathogenesis is most likely multifactorial. Although significant, genetic abnormalities are not
understood well enough to allow the formulation of a sequence of progression to the development
of gastric carcinoma. One postulation on the development of this disease involves a succession of
histologic changes that commence with atrophic gastritis, advance to mucosal metaplasia, and
eventually result in malignancy.

Certain genetic or familial syndromes, gastric colonization by H. pylori, and conditions resulting in
gastric dysplasia have been reported as definite risk factors for the development of stomach
cancer. The use of tobacco, dietary risk factors (i.e., high intake of salted, smoked, or pickled
foods, and low intake of fruits and vegetables), and excess alcohol consumption also have been
implicated as causal elements.

Certain risk factors could be related more to certain histology or certain anatomical site within the
affected organ as in this case Esophagus or Stomach. See the figure below for further illustrations.

OSCC: Oesophageal Squamous Cell Carcinoma

OAC: Oesophageal Adenocarcinoma

BO: Barret's Oesophageatis

GC: Gastric Cancer
Gastric Cancer-Histology
Histology of Gastric Cancer

Ninety-five percent of all malignant gastric tumors are adenocarcinomas; the remaining 5 percent
include lymphomas, stromal tumors, and other rare tumors.

The overall declining incidence of gastric carcinoma is related to distal stomach tumors caused
by Helicobacter pylori infection.

Proximal stomach tumors of the cardiac region have actually increased in incidence in recent
years. This trend has been attributed to the increased incidence of Barrett’s esophagus and its
direct correlation with the development of esophageal adenocarcinoma.
Gastric Cancer-Clinical Presentation
Clinical Presentation

Most patients are asymptomatic in the early stages of gastric cancer and have advanced disease
by the time of presentation.

In general, the most common presenting symptoms included weight loss and abdominal pain. Epigastric fullness, nausea, loss of appetite, dyspepsia, and mild gastric discomfort may also occur. Dysphagia may be a prominent symptom for patients with tumors in the cardia or gastroesophageal junction. In patients with pyloric tumors and tumors located in the antrum, vomiting and gastric outlet obstruction may occur. Gastrointestinal bleeding is less common, and only seen in about 20% of cases.
Gastric Cancer- Diagnosis
Diagnosis

Diagnosis of any medical condition, of course, will start with proper history and focused clinical
examination, which both can rais the suspicion of a particular medical condition/s.

The initial diagnosis of gastric carcinoma often is delayed because up to 80 percent of patients are
asymptomatic during the early stages of stomach cancer. In Japan, a higher incidence of
adenocarcinoma and rigorous screening processes have led to a greater number of cases of
gastric cancer being detected in an early stage.

Physical Examination

Physical examination may provide clues to diagnose gastric cancer. The presence of anemia,
occult blood in the stool, and weight loss may suggest malignancy. A midepigastric palpable mass or nodular liver may be helpful in localizing the process to the abdomen.

The patient may appear completely healthy on physical exam. Additional findings may include:
abdominal mass, liver metastases, gastric distention, weight loss, upraclavicular adenopathy (Virchow’s node), rectal mass (Blumer’s shelf), enlarged ovary (Krukenberg’s syndrome), or umbilical metastases (Sister Mary Joseph’s

node).

Migratory phlebitis (Trousseau’s syndrome), seborrheic keratosis and freckles (Leser-Trélat sign),
muscle weakness, splenomegaly, ascites, obstructive jaundice, and peritoneal carcinomatosis may be noted in more advanced disease.

Investigation:

Endoscopic Diagnosis

Endoscopy provides the most specific and sensitive means of diagnosis of gastric cancers.
Gastrointestinal endoscopy allows the physician to visualize and biopsy the mucosa of the esophagus, stomach, duodenum, and most of the jejunum.
More than 90% of gastric cancers are detected by upper endoscopy and biopsy. Endoscopy
facilitates accurate visualization, histological confirmation and typing.

Endoscopic ultrasound accurately delineates the depth of tumor invasion through the layers of the
gastric wall and lymph node involvement. EUS is performed after the initial esophagogastroduodenoscopy (EGD).

Radiology

A double-contrast barium swallow, a cost-conscious, noninvasive, and readily available study, may
be the initial step

After the initial diagnosis of gastric cancer is established, further evaluation for metastases is
necessary to determine treatment options. Computed tomographic (CT) scanning is a useful
method of detecting liver metastases, perigastric involvement, peritoneal seeding, and involvement
of other peritoneal structures (e.g., ovaries, rectal shelf).
Questions-4
Regarding Gastric Cancer:

A. Incidence has increased in developing countries.

B. The lesser curvature is the usual primary affected site within the stomach.

C. All gastric cancer patients are H. Pylori positive.

D. Lymphoma is the most common subtype.

E. Usually diagnosed during the early stages.

A. Incidence has increased in developing countries.

Score: 1

B. The lesser curvature is the usual primary affected site within the stomach.

Score: 0

C. All gastric cancer patients are H. Pylori positive.

Score: 0

D. Lymphoma is the most common subtype.

Score: 0

E. Usually diagnosed during the early stages.

Score: 0
Treatment Esophageal-Gastric Cancers
Treatment

Treatment of any cancer type will depend on two important factors:

1. Patient factor: This indicates the presence of additional medical conditions (comorbid
conditions) such as heart failure, diabetes,...). This may affect the treatment decision.
2. Disease factor: This depends mainly on the stage of the tumor at time of diagnosis. Of
course, other features such as histology, grade, molecular profile, etc are also playing a
role.

Staging use TNM system.

T= Tumor

N= Lymphnode

M= Metastatsis

For hollo organs such as the esophagus, stomach, colon, T will depend on the depth of
penetration. See the picture below.
Treatment can be curative in the early stages of the disease and it is usually surgery, however in
advanced stages, other treatment options will be used such as chemotherapy, targeted agents,
radiotherapy,...
 References

1- Davidson's Principles and Practice of Medicine. 23rd Edition

2- Harrison's Principles of Internal Medicine

3- https://www.aafp.org/home.html

Please feel free to contact me in case you have any related questions to the topic under discussion.

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