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GI Investigation and Treatment Protocols

This document outlines the standard workup and evaluation process for patients presenting with cancers of the stomach, esophagus, colon, rectum, liver, pancreas, and periampullary region at the GI department. It details the necessary basic blood investigations, imaging studies, endoscopies and biopsies to be performed based on the suspected tumor location. Treatment planning is discussed including options for surgery, chemotherapy or palliation depending on tumor stage and medical fitness. All patients must be discussed with a GI consultant within one week for further management.

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Praveen Ravishankaran
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68 views6 pages

GI Investigation and Treatment Protocols

This document outlines the standard workup and evaluation process for patients presenting with cancers of the stomach, esophagus, colon, rectum, liver, pancreas, and periampullary region at the GI department. It details the necessary basic blood investigations, imaging studies, endoscopies and biopsies to be performed based on the suspected tumor location. Treatment planning is discussed including options for surgery, chemotherapy or palliation depending on tumor stage and medical fitness. All patients must be discussed with a GI consultant within one week for further management.

Uploaded by

Praveen Ravishankaran
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

GI PROFORMA

Investigations:

Basic Blood investigations : Hemogram, RFT, LFT, Serum Electrolytes,


Coafgulation prolife , Viral Serology.

STOMACH and OG junction tumours:

Investigations to be given at admission:


- Basic Blood investigations
- Chest X ray, ECG
- CECT abdomen and pelvis ( Not to be repeated if good quality
CECT available with the patient)
- Upper GI endoscopy and biopsy ( If already done elsewhere, OGD
to be repeated only if the extent is not clearly mentioned or if
biopsy does not provide the required information)
- Submit outside slides for review
- FNAC from Supraclavicular node if suspicious.

Upper GI endoscopy( Information to be documented):


- Location of OG junction in cms
- Siewerts classification of the tumour
- Extent of the tumour
- Distensibility of the stomach
- Whether scope passes beyond the tumour
- Biopsy taken or not ( Biopsy raised should contain the necessary
details of the patient and the descripition of the disease status)
( Patient should be asked to review at OPD on a Wednesday/ Saturday for
biopsy reports)

Patient has to be put up to the GI consultant within 1 week of the


patient’s arrival at the OPD.

Plan for the patient:

1)OG junction tumours :


a) Assign a Siewerts Category
b) Smoking cessation , counselling and screeninf for family history if
applicable.
c) Pelvic CT as clinically indicated and PET CT if no evidence of
metastatic disease( after consultant review only).
d) Biopsy from metastatic lesion as clinically indicated( after
consultant review)
e) Assign a TNM staging for the OG junction tumour

Surgical plan :

1)For stage I-III:

Options : Preoperative chemoradiation/ definitive Chemoradiation /


Straight surgery
a) If siewerts Category 1 – Plan for Transhiatal esophagectomy
b) If siewerts Catergory 2 – Plan for extended total gastrectomy
c) If siewerts category 3 – plan for Total gastrectomy

2)For stage IV/Unresectable locally advanced :


Palliative chemotherapy / Best supportive care

Plan for STOMACH:

1) Assign TNM staging for the tumour


2) If GOO – To admit the patient . Electrolyte correction to be done.
Work up for straight surgery
3) If No GOO – To work up pateint for Diagnostic laparoscopy

Options :

Operable cases :
1) With Gastric outlet obstruction : Straight surgery
2) Without Gastric outlet obstruction : For D lap  If no peritoneal
disease  Neoadjuvant chemitherapy  Surgery
3) Medically fit, unresectable cases  For NACT  reassess for
surgery
4) Medically unfit , Laparoscopic findings of metastatic disease  for
palliative management.

COLON:

Investigations to be given at admission:


- Basic Blood investigations
- Chest X ray, ECG
- CECT abdomen and pelvis ( Not to be repeated if good quality
CECT available with the patient)
- Colonoscopy and biopsy ( If already done elsewhere, colonoscopy
to be repeated only if the extent is not clearly mentioned or if
biopsy does not provide the required information)
- Submit outside slides for review
- Serum CEA

Proper instructions regarding the colonoscopic preparation has to be


provided to the patient

Colonoscopy ( Information to be documented):


- Preparation status
- Type of the growth
- Distal and Proximal extent of the tumour
- Whether scope passes beyond the tumour
- Status of the remaining colonic mucosa.
- Biopsy taken or not ( Biopsy raised should contain the necessary
details of the patient and the descripition of the disease status)
( Patient should be asked to review at OPD on a Wednesday/ Saturday for
biopsy reports)
If preparation for colonoscopy is inadequate/ not performed due to some
reason, the patient should be put up to the respective consultant on the
next GI OPD day and not reposted again)

Patient has to be put up to the GI consultant within 1 week of the


patient’s arrival at the OPD.

Treatment plan:
1) Pedunculated polyp with invasive cancer  Completely excised with
negative margins  Observe.
2) Sessile polyp with invasive cancer  Completely excised with
negative margins  Observe / Colectomy with enbloc removal of
nodes.
3) Polyps  Fragmented specimen, margins could not be assessed 
Colectomy with enbloc removal of the nodes.
4)
RECTUM:

Investigations to be given at admission:


- Basic Blood investigations
- Chest X ray, ECG
- MRI abdomen and pelvis ( Not to be repeated if good quality MRI
available with the patient)
- Colonoscopy and biopsy ( If already done elsewhere, colonoscopy
to be repeated only if the extent is not clearly mentioned or if
biopsy does not provide the required information)
- Submit outside slides for review
- Serum CEA

Proper instructions regarding the colonoscopic preparation has to be


provided to the patient

Colonoscopy ( Information to be documented):


- Preparation status
- Type of the growth
- Distal and Proximal extent of the tumour
- Whether scope passes beyond the tumour
- Status of the remaining colonic mucosa.
- Biopsy taken or not ( Biopsy raised should contain the necessary
details of the patient and the descripition of the disease status)

( Patient should be asked to review at OPD on a Wednesday/ Saturday for


biopsy reports)
If preparation for colonoscopy is inadequate/ not performed due to some
reason, the patient should be put up to the respective consultant on the
next GI OPD day and not reposted again)

Patient has to be put up to the GI consultant within 1 week of the


patient’s arrival at the OPD.
PERIAMPULLARY AND HEAD OF PANCREAS :

Investigations to be given at admission:


- Basic Blood investigations
- Chest X ray, ECG
- CECT abdomen and pelvis ( Not to be repeated if good quality
CECT/MRCP available with the patient)
- Upper GI endoscopy/ Side viewing scopy and biopsy ( If already
done elsewhere, OGD to be repeated only if the extent is not
clearly mentioned or if biopsy does not provide the required
information)
- Submit outside slides for review
- Serum CA 19-9

Upper GI endoscopy( Information to be documented):


- Location of OG junction in cms
- Status of gastric mucosa
- Location of the tumour
- Biopsy taken or not ( Biopsy raised should contain the necessary
details of the patient and the descripition of the disease status)
( Patient should be asked to review at OPD on a Wednesday/ Saturday for
biopsy reports)

ERCP and stenting to be done(After concurrence with GI consultant)


- Planned for neoadjuvant therapy
- Long waiting list
- Impaired coagulation profile
- Hepatorenal syndrome

Patient has to be put up to the GI consultant within 1 week of the


patient’s arrival at the OPD.
BODY AND TAIL OF PANCREAS :

Investigations to be given at admission:


- Basic Blood investigations
- Chest X ray, ECG
- CECT abdomen and pelvis ( Not to be repeated if good quality
CECT available with the patient)
- Submit outside slides for review( If CT guided/EUS guided FNAC
has been done elsewhere)
- Serum CA 19-9

Patient has to be put up to the GI consultant within 1 week of the


patient’s arrival at the OPD.

LIVER :

Investigations to be given at admission:


- Basic Blood investigations
- Chest X ray, ECG
- Triple phase helical CT abdomen and pelvis ( Not to be repeated if
good quality CECT available with the patient)
- Submit outside slides for review ( If guided FNAC has been done
elsewhere)
- Guided FNAC/Biopsy from the liver lesion if planning for
palliative therapy. Inj Vitamin K to be given IM x 3 days
- Serum CA 19-9
- Child Pugh Score to be documented (Ascitis, Encephalopathy,
[Link], [Link] and PT/INR)

Patient has to be put up to the GI consultant within 1 week of the


patient’s arrival at the OPD.

Common questions

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The criteria for repeating a colonoscopy or upper GI endoscopy hinge on the clarity and sufficiency of initial findings. If the extent of the tumor is not clearly documented or the biopsy doesn't yield required diagnostic information, a repeat procedure is mandated. This ensures complete and accurate assessment to guide treatment planning. The document emphasizes that outside slides must also be reviewed, and interventions are to be repeated only when necessary to avoid redundant procedures while maintaining comprehensive patient evaluation .

For pedunculated polyps with invasive cancer that are completely excised with negative margins, observation is typically recommended. Conversely, for sessile polyps with invasive cancer, even when completely excised with negative margins, there's a consideration for observation or possibly a colectomy with enbloc node removal. This difference reflects the greater potential for sessile polyps to leave behind residual disease due to their flat structure .

The decision to opt for neoadjuvant chemotherapy versus straight surgery is dictated by the tumor's operability and the presence of gastric outlet obstruction (GOO). In cases with GOO, direct surgery is advised to quickly alleviate symptoms. Without GOO, neoadjuvant chemotherapy is considered if there is no peritoneal disease post-diagnostic laparoscopy. This approach allows for tumor downstaging and potentially more successful surgical outcomes by reducing tumor burden preoperatively .

Performing a biopsy on metastatic lesions is a crucial step when managing OG junction tumors, as it provides histopathological evidence needed for accurate TNM staging. Precise staging informs treatment decisions, such as the feasibility of surgical intervention or the need for neoadjuvant therapies. Biopsying metastatic sites can confirm cancer spread and help tailor palliative options if curative measures are no longer viable, ensuring that patient management aligns with their clinical status .

The preparation status for procedures such as colonoscopy is crucial, as inadequate preparation can obscure visualization, thereby impacting diagnostic accuracy. If preparation is inadequate, the procedure may need to be repeated or the patient consulted further with a GI specialist to ensure the scope can pass beyond the tumor and the colonic mucosa's status is clear. This ensures that biopsies and subsequent treatment plans are based on accurate and complete information .

The Siewert classification is critical in the management of OG junction tumors as it helps to determine the surgical plan based on the tumor's location. For example, a Siewerts Category 1 tumor calls for a Transhiatal esophagectomy, Category 2 requires an extended total gastrectomy, and Category 3 necessitates a total gastrectomy. This classification guides the treatment approach, including the choice between surgery and chemoradiation, thus optimizing patient outcomes .

CECT (Contrast-Enhanced Computed Tomography) and MRI (Magnetic Resonance Imaging) play complementary roles in rectal cancer management. CECT is typically used to assess distant metastases and pelvic disease, providing insight into the systemic spread. MRI, on the other hand, is preferred for detailed local staging due to its superior soft tissue resolution, which enhances visualization of the rectal wall and surrounding structures. This detailed imaging is critical for assessing tumor depth and involvement in local tissues, which is essential for planning surgical margins and evaluating the feasibility of surgical resection .

TNM staging informs the treatment strategy for stomach tumors by categorizing the extent of cancer and helping to decide between surgical and non-surgical management. For instance, operable cases with gastric outlet obstruction are directly addressed with surgery. However, for cases without obstruction, diagnostic laparoscopy is performed to check for peritoneal disease, following which neoadjuvant chemotherapy might be considered based on the TNM stage. For unresectable or medically unfit cases revealed by laparoscopy, palliative management is advised .

The protocol for managing liver lesions involves conducting basic blood investigations followed by a triple-phase helical CT scan, crucial for detailed liver imaging. This imaging helps visualize the blood supply to the liver and any lesions, aiding in planning interventions such as biopsies or palliative therapies. Additionally, the document requires reviewing slides from existing FNAC or biopsy, ensuring all prior findings are validated. This structured approach ensures a thorough assessment before initiating Vitamin K administration or documenting the Child-Pugh score for overall liver function evaluation .

Serum CA 19-9 is highlighted as a valuable biomarker in the diagnosis and treatment planning for pancreatic lesions, especially for periampullary and head of pancreas cases. Its presence helps in the initial diagnosis and in monitoring response to treatment. Moreover, an elevated CA 19-9 level can indicate the presence of malignancy and may guide the decision to proceed with more invasive investigations or interventions such as ERCP and stenting .

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