Epidemiology of digestive tract cancers in India. V. Large and small bowel.

The large bowel is a leading site for cancers in developed countries whereas small bowel cancers are rare worldwide. The incidence rates of both large and small bowel cancer are low in India, and rectal cancer is more common than colon cancer. The incidence rates of colon cancer in eight population registries vary from 3.7 to 0.7/100,000 among men and 3 to 0.4/100,000 among women. For rectal cancer the incidence rates range from 5.5 to 1.6/100,000 among men and 2.8 to 0/100,000 among women. One intriguing observation is the occurrence of rectal cancer in young Indians. Rural incidence rates for large bowel cancers in India are approximately half of urban rates. Based on data from eight registries, we estimate that, in the year 2001, the incidence of large bowel cancer in India will be 18,427 in men and 13,092 in women. Immigrant studies reveal an increase in incidence as compared to the rates in native counterparts. Reliable time trends for India are available only from the Bombay registry. Significant increase in the incidence of colon cancer has been reported for both men and women over two decades, but the rates of rectal cancer are steady. The low incidence of large bowel cancers in Indians can be attributed to high intake of starch and the presence of natural antioxidants such as curcumin in Indian cooking. The role of hereditary factors has been evaluated in a few studies. Some studies have reported the occurrence of both FAP and HNPCC in India. There are no Indian studies on large bowel cancer prevention. The prevalence of adenomas is rare in elderly Indians undergoing colonoscopy, even in those with large bowel cancers. Small bowel cancers are extremely rare in India and no analytical studies have been published. Hospital-based data suggest that lymphomas of small bowel are more common than carcinomas. In conclusion, the incidence of large and small bowel adenomas and cancers is low in Indians. Increase in the incidence of large bowel cancers in immigrants and urban Indians compared to rural populations supports a role for environmental risk factors including diet. High rates of rectal cancers in young Indians could suggest a different etiopathogenesis, which is neither inherited nor traditional diet-related.

Dilatation of radiation-induced esophageal strictures under sublingual buprenorphine analgesia: a pilot study.

BACKGROUND: Pain during dilatation of radiation strictures is a troublesome complaint. There is little information on sedation and analgesia during this procedure. We performed a pilot study to compare the analgesic efficacy of sublingual buprenorphine and intravenous pentazocine during dilatation of radiation-induced esophageal strictures. METHODS: Thirty-one patients with esophageal cancer who had radiation-induced strictures were randomized to receive either buprenorphine 0.2 mg sublingually two hours before dilatation (n = 17) or pentazocine 30 mg intravenously five minutes before dilatation (n = 14). Dilatation was considered successful if it could be performed to 12 mm diameter or more. Pain experienced during dilatation was graded as mild, moderate or severe. RESULTS: Sixteen patients in the buprenorphine group and 12 in the pentazocine group were dilated to > 12 mm size (p = ns). Twelve and nine patients respectively in the two groups experienced mild or no pain; ten and six patients had minor side-effects (p = ns). CONCLUSION: Buprenorphine is useful for sedoanalgesia during dilatation of radiation-induced strictures of the esophagus.

Rectal lymphogranuloma venereum in association with rectal adenocarcinoma.

Rectal involvement in lymphogranuloma venereum (LGV) is more common in women. Inguinal bubo is often absent and the patient seeks medical attention only at a late stage when rectal stricture has developed. LGV rectal stricture resembles and is known to predispose to rectal cancer. Hence it is necessary to rule out rectal malignancy in patients with LGV stricture. We report a case of rectal LGV associated with rectal adenocarcinoma.

Unusual bone metastasis as the initial symptom of gastric cancer--a report of four cases.

Four cases of gastric cancer presenting with bone pain due to metastasis as the initial symptom are reported. Investigations revealed solitary osteolytic metastasis in the mandible in one, and left scapula in one patient. Third patient had multiple osteosclerotic metastasis with elevation of acid phosphatase and another had multiple discrete osteolytic metastasis simulating multiple myeloma. All the primary gastric cancers were poorly differentiated adenocarcinoma and three were of Borrman type III on gross appearance. One patient had sparing of the liver inspite of extensive metastasis. Chemotherapy was in effective in two patients and the prognosis was uniformly poor.

Multiple lymphomatous polyposis of the gastrointestinal tract.

We report two rare cases of multiple lymphomatous polyposis of the gastrointestinal tract. Both patients had multiple polypoidal defects involving large segments of gastrointestinal tract. The histopathology in both cases was diffuse poorly differentiated lymphoma. One case had multiple relapses despite treatment and died after 58 months. The second patient died following induction chemotherapy.

Role of endoscopic ambulatory laser therapy in palliation of malignant colorectal diseases.

BACKGROUND: Endoscopic laser therapy is widely used in the palliation of advanced malignant colorectal diseases. The role of this therapy in improving the quality of life of these patients needs adequate assessment. METHODS: Nine patients with advanced colorectal cancers and three patients with secondary colorectal involvement by pelvic cancers underwent endoscopic Nd:YAG laser therapy for palliation using non-contact laser guides for tumor bleeding alone (n = 12) or associated with obstruction (n = 7). The therapy was performed on an outpatient basis in 9 of the 12 patients. One patient was lost to follow up. RESULTS: Symptom control was achieved in all the 11 bleeding tumors and in 5 of the 7 obstructive tumors. There were no major complications. Three patients had no improvement in the quality of life in spite of control of symptoms. CONCLUSION: Ambulatory endoscopic laser therapy is a minimally invasive, safe and effective method of palliation for selected patients with non-resectable malignant colorectal tumors.

A prospective study of radiation induced damage of pancreatic ducts.

To study radiation-induced pancreatic duct damage, endoscopic retrograde pancreatograms of 11 patients with primary gastric lymphoma who had completed chemotherapy and moderate dose external radiation therapy were compared with those of 22 normal subjects. No significant alteration was seen in the length and caliber of the main pancreatic duct and number of side branches. Clubbing of one or two side branches was observed in four patients who had received radiation (p = ns). We conclude that significant structural changes do not develop in the pancreas following moderate dose upper abdominal radiation.

Out-patient esophageal dilation: an experience in 130 patients using Savary-Gilliard dilators.

Experience of outpatient esophageal dilation using Savary-Gilliard dilators in 130 patients during a 17 month period is reported. The strictures were radiation induced (48), tumoral stenoses (40), anastomotic (16) and due to other causes (26). Both fluoroscopy and endoscopy were used in 58%, endoscopy alone in 23% and fluoroscopy alone in 19% of patients for placement of the guide wire. One hundred and twenty six stricture dilations (97%) were technically successful. Eighty one (62%) patients could be dilated to 14 mm or more. One hundred and nineteen (94%) patients were dilated in one or two sessions. Among the 109 patients who followed up, dilation was successful in providing adequate dysphagia relief in 97 patients and facilitated the performance of other therapies in 9 patients. Major complications included severe continuous chest pain (1 case), hematemesis (2), fever (4) and transient stridor (2). The patient with persistent pain and 9 patients undergoing other therapies required hospitalization. There were no perforations or death. We conclude that esophageal dilation with Savary-Gilliard dilators is safe and effective even in tumors and post-radiation strictures. It can be performed on an outpatient basis in a majority of patients.

Percutaneous endoscopic gastrostomy for long term enteral nutrition.

BACKGROUND. Percutaneous endoscopic gastrostomy for long term enteral nutrition is often indicated in patients with head, neck and oesophageal cancer but despite its growing popularity elsewhere, it is not widely used in India. METHODS. Between March 1990 and July 1991, we performed percutaneous endoscopic gastrostomy in 54 patients. The primary sites of tumour were the hypopharynx (11), oral cavity (7), tongue (7), cricopharynx (7), oesophagus (16) and other sites (6). The indications were difficulty in swallowing following treatment (22), preoperative nutritional support (7) and terminal care (21). In 49 patients, it was performed by the 'pull' technique in the endoscopy room under local anaesthesia and mild sedation. Indigenously prepared tubes and blenderised foods were used. Fifteen patients underwent dilatation of the tumour prior to the gastrostomy. RESULTS. The procedure was successful in 50 (93%) patients. Three failures were caused by obstructing tumours and one by a previous gastric resection. Feeding was started 18 to 24 hours after the procedure in 48 patients. No major complications occurred but minor complications were seen in 11 (22%) patients. Fourteen patients had their gastrostomy tube removed after 2 to 6 months of use while 15 patients undergoing therapy or with persistent dysphagia were on gastrostomy feeds for 1 to 6 months. Of the 21 terminally ill patients, 8 died, 6 were lost to follow up and 7 were on feeds for 1 to 6 months. CONCLUSIONS. Percutaneous endoscopic gastrostomy is a simple, safe and effective method for long term enteral feeding. Indigenous tubes and home made blenderised foods are adequate substitutes for the more expensive commercial kits and enteral formulations.

Outpatient dilation of anastomotic strictures of the upper gastrointestinal tract.

Anastomotic upper gastrointestinal strictures in 32 patients were dilated on an outpatient basis. Strictures had developed following resection-anastomosis of the esophagus in 27, total esophagectomy in two and total/partial gastrectomy in three patients. Patients with benign anastomotic strictures (group A; n = 21) presented within 6 (median 2) months of surgery while those with recurrent tumors at the site of anastomosis (group B; n = 11) presented 7 (median 14) months later. Dilation using Savary-Gilliard (n = 24), through the scope balloon (n = 2) and Eder Puestow (n = 1) dilators or a combination of these (n = 1) was possible in 20 (95%) patients in group A and 8 (73%) patients in group B. All the 28 patients had relief of dysphagia. Median duration of response after first dilation was 4.2 and 1.2 months in groups A and B respectively. Nature of previous surgery, length of the remaining stomach and recurrence of tumor at anastomosis appeared to affect the technique and outcome of dilation. Savary-Gilliard dilators can be used in a majority of patients except those with short stomachs where through the scope balloon dilators may be preferred.

Familial polyposis coli with villous adenoma of ampulla of Vater.

Adenoma of the ampulla of Vater is one of the extracolonic manifestations of familial polyposis coli (FPC). We report three patients with FPC in whom villous adenoma of the ampulla was detected. An adenoma carcinoma sequence has been suggested in such lesions.

Double primary neoplasms of the stomach and kidney.

We report a case of synchronous double primary neoplasms of the stomach and kidney. Immunohistochemistry confirmed the two primaries to be of different origin based on antigen expression.

Medication induced esophageal injury.

Five patients of medication-induced esophageal injury are reported. A history of ingestion of medications preceding the onset of dysphagia was obtained in all patients. Endoscopy revealed localised mucosal ulceration with surrounding edematous mucosa at the level of the aortic arch in four, and in the retro-cardiac esophagus in one patient. The medications involved were sustained release potassium chloride, doxycycline, ibuprofen, and an unidentified antibiotic and antihypertensive (one each). Healing of the esophageal ulcers was confirmed in all the patients by endoscopy.

Association of esophageal cancer and esophageal varices.

Of the 312 cases of esophageal cancer seen over 2 years, four patients had associated varices. Three patients gave history of alcohol abuse. All had malnutrition and splenomegaly. Endoscopic biopsies were safe in the presence of varices. External radiation did not have any untoward effect on the varices. Prophylactic sclerotherapy was not required in these patients. The association between esophageal carcinoma and varices could be secondary to alcohol consumption or merely coincidental.