Carcinoma Oesophagus

Dr Sunila BHMS,MD(Hom)
Name   : Ayisha
I P No: 678
D O A: 27/9/2005

Presenting Complaints

• Obstructive feeling at throat (5 months)   < After eating
• Difficulty in swallowing especially for solids (5 months)
• Cough (1 week)                <lying down & night
• Weakness (5 months)
• Headache especially on right forehead (5 months)

History of presenting complaint
Obstructive feeling at the throat and difficulty in swallowing solids and liquids started 5 months back and diagnosed as carcinoma oesophagus. There is vomiting of food after eating.

History of past illness

1. History of asthma                : 3 years back      Took Ayurvedic treatment

2. H/O Rheumatic complaint   : 3 years back      Took Ayurvedic treatment

Personal History

• Place of birth          : Balussery
• Educational status: Illiterate
• Religion                 : Muslim
• Appetite     : good; Prefers warm food.
• Thirst         : decreased; Prefers warm drinks.
• Sleep           : decreased
• Stool           : constipated
• Urine          : no complaints
• Sweat          : generalised 

Psychic features She is mild and gentle. She prefers company.

Investigations 

Endoscopy (26/05/05) 

Oesophagus: There is a large nodular growth arising from the oesophagus at 32cms and extending for about 6cms proximally.

Impression  : arcinoma oesophagus.

Provisional diagnosis  : Carcinoma oesophagus 

Physical examination 

Pulse: 70/mt         B P: 120/ 80 mm of Hg       Temp: 98◦ F 

General Survey

• Moderately built and nourished
• Pallor present
• No cyanosis, not icteric.
• No clubbing
• No lymphadenopathy and No pedal oedema

Systemic Examination 

• No congestion of nasal mucosa & no deviation of nasal septum & no nasal polyp.
• Uvula centrally placed & no tonsillar enlargement.

Examination of lower Respiratory tract 

Inspection

• Trachea appears to be centrally placed; chest wall bilaterally symmetrical
• No kyphosis, scoliosis or lordosis; no prominent vessels and visible pulsations

Palpation :   No palpable swelling. Trachea centrally placed. Apex beat palpable.

Percussion : Normal lung resonance over all lung fields

Patient is conscious, intelligent, normal behaviour, past and present memory present, orientation of time, place and person present, no hallucination, delusion, illusion and speech normal.

• Gag reflex present
• Uvula centrally placed
• Hypoglossal Nerve: Can move tongue in all directions
• Sensory System: With in normal limit
• Examination of motor System: Within normal limits
• Signs of meningeal irritation: No signs of meningeal irritation 

Analysis of symptoms 

Evaluation of symptoms

 Totality of symptoms

• 1.      Prefers company
• 2.      Patient desires warm drinks.
• 3.      Patient desires warm food.
• 4.      Patient desires pungent things.
• 5.      Weakness
• 6.      Carcinoma oesophagus
• 7.      Difficulty in swallowing solids
• 8.      Obstructive feeling at throat
• 9.      Vomiting of food
• 10.  Cough < night.
• 11.  Cough <lying down.
• 12.  Right sided headache 

Miasmatic cleavage 

Rubrics selected 

• MIND COMPANY desire for

• GENERALITIES WEAKNESS
• STOMACH DESIRE warm drinks
• STOMACH DESIRE warm food
• STOMACH DESIRE pungent things
• GENERALITIES CANCEROUS affection
• THROAT OBSTRUCTION
• THROAT SWALLOWING DIFFICULT solids
• STOMACH VOMITING food
• COUGH NIGHT
• COUGH LYING agg
• HEAD PAIN forehead

Medicines

• Ars alb- 26/11
• Lycopodium- 25/12
• Lachesis- 20/7
• Nuxvomica- 10/5
• Pulsatilla- 14/5
• Thuja- 8/6

Prescription

• 27- 9- 05- vomiting immediately after food- Nuxvomica30/ 2 dose
• 28- 9- 05- vomiting relieved-sac lac/ 2 dose
• 30- 9- 05- Ars alb 30/ 2 dose
• 2- 10- 05- she has symptomatic relief- sac lac/ 2 dose
• 15- 10- 05- Thuja 200/ 1 dose
• 5- 11-05-Ars alb 200/ 1 dose
• 8- 11- 05- she expired peacefully.

Carcinoma of the oesophagus
Cancer of the oesophagus is the ninth most common cancer in the world. It is in general a disease of mid to late adulthood with a poor survival rate. Only 5-10% of those diagnosed will survive for 5 years.

Squamous cell cancer and adenocarcinoma are the commonest types. Squamous cell carcinoma affects the upper ⅔rd of the oesophagus and adenocarcinoma affects the lower ⅓rd. But there are frequent exceptions to this rule. Oat cell cancer occurs occasionally.  World wide it is the squamous cell cancer that is the commonest, but adenocarcinoma is the commonest type in the westernized countries.

Aetiopathogenesis

1)      Precancerous conditions: Reflux oesophagitis with Barrett’s oesophagus.

Reflux oesophagitis: Extensive inflammation of the lower oesophagus by the gastric acid refluxing into the lower oesophagus from the stomach. 

Barrett’s oesophagus: One of the complications of reflux oesophagitis. In this condition, columnar epithelium is present for more than 3cms above the cardio-oesophageal junction. It is due to metaplasia; (The entire oesophagus is lined with squamous epithelium except the last 3cms which is lined by columnar cells).

Plummer Vinson syndrome:  in which there is severe spasm of circular muscle fibers at the cricopharyngeal sphincter level and it is associated with the development of postcricoid web.

Achalasia Cardia: It is also called cardiospasm because of severe spasm of circular muscle fibers of the lower end of the oesophagus.

Corrosive strictures

2) Possible aetiological factors:

• Chronic smoking, tobacco chewing, spicy food with spirits are the common causes of ca oesophagus in India.
• Smoked salmon fish consumption is common in Japan, wherein the incidence of this carcinoma is high.
• The cause of disease in the endemic areas is possibly due to the production of a carcinogenic microtoxin, together with nutritional deficiencies in the population.

Sites:

• 50%- middle ⅓rd of the oesophagus
• 33%- lower ⅓rd of the oesophagus
• 17%- upper ⅓rd of the oesophagus

Types 

• 1. Epitheliomatous ulcer (carcimatous) with everted edges.
• 2. Proliferative growth (cauliflower) which commonly bleeds.
• 3. Infiltrative variety or annular stenosing variety, which gives rise to early dysphagia.

Clinical Features

1.Men above 60 years of age are commonly affected.

2. Dysphagia is the usual presenting feature and is generally a sign of advanced disease. Dysphagia mainly for solids. It takes 18 months for dysphagia to develop. It means ¾th of the circumference of the lumen involved by the growth.

3. Oesophageal regurgitation of the food contents.

4. Haematemesis not very common contains streaks of blood.

5. Melaena is rare.

6. Loss of appetite.

7. Loss of weight and cachexia.

8. Dehydration

9. Back ache indicates enlarged lymph nodes (Coeliac)

Patients with early disease may present with rather nonspecific dyspeptic symptoms or a vague feeling of something that is not quiet right while swallowing.

Hoarseness due to recurrent laryngeal nerve palsy is a sign of advanced and incurable disease.

Spread

1. Local spread or Direct spread

Mucosal ulceration spreads to submucosa. Later it causes fibrosis and the lumen gets narrowed. The spread occurs transversely and longitudinally. Once it spreads to the serosal coat, the structures in the vicinity are involved.

• a) When trachea is involved, tracheo-oesophageal fistula develops (carcinoma upper ⅓rd).
• b) Broncho-oesophageal fistula (carcinoma middle ⅓rd)
• c) Oesophago-aortic fistula results in massive bleeding. (One of the causes of death.) 

All these complications are contraindications for surgery and radiotherapy.

2. Lymphatic spread

• §  Upper oesophagus: drains to left and right supra clavicular nodes
• §  Middle oesophagus: to the tracheobronchial nodes and paraoesophageal nodes
• §  Lower oesophagus: drains into lymph nodes along the lesser curvature of stomach and then into celiac nodes. 

3. Blood Spread

It results in secondaries in the liver, which clinically appear as enlarged liver. Later ascites and rectovesical deposits occur. Palpable left supraclavicular nodes in advanced disease. This sign is described as Troisier’s sign.

Investigations:

• 1. Hb% is low, which causes generalized weakness.
• 2. Liver function test (LFT): if secondaries in liver occur.
• 3. Ultra sound is done to rule out liver secondaries, lymph nodes in the porta hepatic, coeliac nodes etc.
• 4. Barium swallow demonstrates irregular, persistent, intrinsic filling defect.
• 5. Oesophagoscopy to visualize the growth and to take biopsy.
• 6. Chest x-ray to rule out aspiration pneumonia and mediastinal widening.
• 7. Bronchoscopy to rule out involvement of bronchus, as in carcinoma middle ⅓.
• 8. C.T scans of the chest to find out local infiltration.

Treatment – A gastrotomy should never be carried out as the palliation for oesophageal cancer. Palliation in this disease demands relief of dyspagia.

Curative treatment involves radical surgery or radiotherapy.

             I.      Carcinoma upper ⅓rd of oesophagus:-

§  A growth (squamous cell) with secondaries in lymph nodes is treated by external radiotherapy.

§  Small mobile growth: Total oesophagectomy followed by gastric pull up and pharyngogastric anastamosis in neck.

          II.      Carcinoma middle ⅓rd of oesophagus:-

§  It is squamous cell carcinoma.

§  Surgery is difficult due to infiltration of surrounding structures.

§  Radiotherapy is given

§  Due to irradiation, oedema develops causing further narrowing of the liver.

§  Fibrosis develops later in the oesophagus which needs regular dilation by using gum elastic bougies. 

IVOR-LEWIS OPERATION
It is indicated for carcinoma involving lower part of middle ⅓ or upper part of lower ⅓ of oesophagus.

In this operation, abdomen is opened first, stomach is mobilized and the wound is closed. The patient is put in left lateral position, and right thoracotomy is done through 6^th intercostal space. The growth is removed and oesophagogastric anastomosis is done inside thorax, above the level of aortic arch. Hence it is described as a two-stage Ivor-Lewis operation. 

       III.      Carcinoma lower ⅓ of oesophagus :-

a)      A mobile growth:-
Radical oesophagogastrectomy- lower end of oesophagus and upper part of stomach, often spleen; and involved lymphnodes are removed followed by oesophagogastric anastomosis.

b)  A fixed growth :- Celestin tube or Mousseau Barbin’s tube (MB tube) is introduced to reduce dysphagia. This is only a palliative treatment.

Homeopathic theraputics:-

1. Condurango It is given for tumors, stricture of oesophagus, with burning pain behind sternum, where food seems to stick. Vomiting of food and indurations in left hypochondrium, with constant burning pain.

2. Conium: It is mainly given for the paralysis of the oesophagus, difficulty in swallowing food. As the food is about to pass the cardiac orifice, it stops and enters with a great effort. Sense of stuffing in the throat as if something were lodged there. Sense of fullness in throat, pressure in oesophagus as if a rounded body is ascending from stomach. Conium will palliate cancer conditions.

3. Hydrastis:- It is a deep acting remedy given for malignant ulceration. Character of discharge is thick, viscid, ropy yellow mucous. It modifies the pain and restrains the destructiveness. No appetite, no thirst, loathing of food, vomiting all foods. Retains only water and milk. Obstinate constipation with no desire for stool.

4. Phosphorous: – It is given for stricture of oesophagus. Thirst for very cold water. Burning in oesophagus. Regurgitation of all foods, weak empty feeling across the abdomen with occasional shooting pains.

5. Platinum Muriaticum:- Dyspahgia and syphilitic throat. 

6. Baptisia: Constriction and contraction of oesophagus. Great difficulty in swallowing solids and foods. Can swallow liquids only; least solid food gags. Vomiting of solid foods due to spasm of oesophagus.

7. Baryta Carb: – Spasm of oesophagus when food enters causes gagging and choking. Can only swallow liquids.

8. Ars.alb: – Cramp or stricture of oesophagus. Deglutition painful. Burning when swallowing. Food either lodges in oesophagus, producing a feeling of pressure or is ejected as soon as it reaches the pharynx.

9. Ignatia: – Difficulty in swallowing solids or liquids. Sensation of a lump in the throat when swallowing. Hysterical patients.

10. Nuxvomica: – Rough and scraped feeing in the throat. Nausea and vomiting of food. Vomiting gives relief.

REFERENCES:

• Synthesis Repertory by Fredericke Schroyens
• Homoeopathic medical repertory by Robin Murphy
• Repertory of Homoeopathic Materia Medica by J T Kent.
• Allen’s Key notes.
• Boericke’s Materia Medica
• Bailey & love’s short practice of surgery.
• Manipal surgery by Dr. Rajgopal shenoy