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Chapter 4: Gastrointestinal oncology 177

compression due to the median arcuate ligament of the Sex
diaphragm. This may be amenable to surgery. M > F

Geography
Acute intestinal failure
Particularly common in Japan and China.
Definition
Complete necrosis and gangrene of the midgut resulting Aetiology
from cessation of blood flow in the superior mesenteric Squamous carcinoma accounts for more than 90% of
artery. It is predominantly a disease of the elderly. cases. These usually occur in the middle third of the
oesophagus although the lower third may also be af-
Clinical features fected. Aetiological factors include high alcohol con-
There may be a preceding history of non-specific symp- sumption, smoking and chewing betel nuts.
toms (variable abdominal pain, diarrhoea, vomiting and Adenocarcinoma makes up the remaining 10% and
weight loss). Signs of acute intestinal failure include ab- affects the lower third of the oesophagus particularly
dominal tenderness, guarding, loss of bowel sounds and the gastrooesophageal junction possibly following ep-
rigidity, due to perforation. ithelial metaplasia from squamous to columnar cells
as a result of gastro oesophageal reflux (Barrett’s oe-
Investigations sophagus).
Calcification within the abdominal aorta may be evident Familial forms have been noted.
on abdominal X-ray. Gas filled, thickened, dilated bowel
loops and free gas within the peritoneal cavity due to Pathophysiology
perforation may also be seen. Angiography or spiral CT Carcinomas spread along the mucosa and submucosa,
can identify the vascular occlusion. invading adjacent structures and lymph nodes, distant
metastases are rare. Adenocarcinoma tends to metasta-
Management sise earlier.
Following adequate resuscitation laparotomy and resec-
tion(whichmaybemassive)arerequired.Removalofthe Clinical features
vascular occlusion may be possible (e.g. embolectomy). Patients may present with progressive dysphagia, but of-
Asecond look laparotomy can be performed 24 hours tenpresent late with weight loss, anaemia and malaise.
later to re-examine any segment of bowel the viability of On examination there may be cervical lymphadenopa-
which was questionable. thy, cervical mass and hepatomegaly.

Prognosis Investigations
The overall prognosis is poor with 70–90% mortality. If Barium swallow demonstrates an apple core defect or
the patient survives they have considerable malabsorp- stricture without proximal dilatation. Endoscopy al-
tion problems. lows visualisation and biopsy of oedematous friable mu-
cosa proximal to the obstruction. Initial staging (TMN)
should include spiral CT of the chest and abdomen
Gastrointestinal oncology to look for metastases. In the absence of metastases
endoscopic ultrasound is useful to assess operability.
Other techniques include abdominal ultrasound scan-
Oesophageal carcinoma
ning, MRI scanning, bronchoscopy and laparoscopy.
Definition
Primary malignant cancer arising in the oesophagus. Management
Wherever possible surgical resection is the primary

Age treatment with those occurring in the lower third
Rare below the age of 40 years. being the most amenable to surgery. Anatomical