Oesophago-gastric, Hepatobiliary and Pancreatic Cancers

Approximately 2,900 people are diagnosed with a primary oesophago-gastric, hepatobiliary or pancreatic cancer in Scotland every year⁹ and these often present late with consequent poor outcomes, early signs being notoriously vague.

Combinations of symptoms and signs increase the likelihood of cancer, as does increasing age.

The risk of developing an oesophago-gastric cancer is higher in people of East Asian origin. Other risk factors for upper GI cancers (including hepatobiliary and pancreatic) are smoking, alcohol, obesity and family history.

Investigation of oesophago-gastric cancers commonly starts with upper GI endoscopy, whereas the investigation of hepatobiliary and pancreatic cancer starts with CT imaging. If either of these initial investigations is negative, the responsible clinician should consider further investigation prior to discharge back to the original referrer.

An abdominal examination and appropriate blood tests (for example, testing for anaemia, thrombocytosis, renal function, LFTs and HbA1c) should be performed. These can facilitate triage in secondary care. Note that thrombocytosis can be a non-specific risk marker for underlying malignancy.

All people with high risk features should be referred to a team specialising in the management of oesophago-gastric, hepatobiliary or pancreatic cancers, depending on local arrangements.

⁹ Cancer Incidence Report In Scotland (2016) https://www.isdscotland.org/Health-Topics/Cancer/Publications/2018-0424/2018-04-24-Cancer-Incidence-Report.pdf?51368349791

Oesophago-gastric cancer

Urgent suspicion of cancer referral

• Dysphagia (interference of the swallowing mechanism that occurs within five seconds of the swallowing process) or unexplained odynophagia (pain on swallowing) at any age
• Unexplained weight loss, particularly >55 years, combined with one or more of the following features:
  • new or worsening upper abdominal pain or discomfort
  • unexplained iron deficiency anaemia
  • reflux symptoms
  • dyspepsia resistant to treatment
  • vomiting
• New vomiting persisting for more than two weeks

Good practice points

Consider routine referral for people presenting with new upper gastrointestinal pain or discomfort combined with any of the following risk factors:

• family history of oesophago-gastric cancer in a first-degree relative
• Barrett’s oesophagus
• pernicious anaemia
• previous gastric surgery
• achalasia (dysfunction of the oesophageal muscle)
• known dysplasia, atrophic gastritis or intestinal metaplasia
  
  

Primary care management

Dyspepsia without accompanying symptoms or risk factors should be managed according to local or national guidelines

Hepatobiliary and pancreatic cancer

Urgent suspicion of cancer referral

• Painless obstructive jaundice
• Unexplained weight loss, particularly >55 years, combined with one or more of the following features:
  • upper abdominal or epigastric mass
  • new onset diabetes
  • any suspicious abnormality, in the hepatobiliary tract, found on imaging (such as biliary dilatation or pancreatic/liver lesion)
  • new onset, unexplained back pain (consider other cancer causes including myeloma or malignant spinal cord compression)
  • ongoing GI symptoms despite negative endoscopic investigations

Good practice points

• Consider seeking advice in people presenting with new onset GI symptoms with known chronic liver disease

Symptoms and signs of oesophago-gastric and hepatobiliary and pancreatic cancers overlap to a large extent. This table summarises examples of symptoms and signs that can be associated with the different cancers – they are NOT by themselves necessarily reasons to refer.

Associated symptoms/signs	Pancreas, liver and gall bladder cancer	Oesophagogastric cancer
Dysphagia		✔
Iron deficiency anaemia		✔
Haematemesis		✔
Reflux symptoms		✔
Vomiting (>two weeks)	✔	✔
Upper abdominal pain	✔	✔
Unexplained weight loss	✔	✔
Upper abdominal mass	✔	✔
Post-prandial pain	✔	✔
Early satiety (feeling full up after a small amount of food)	✔	✔
Unexplained obstructive jaundice	✔
Unexplained back pain	✔
Late onset diabetes	✔
New onset irritable bowel syndrome overage 40	✔
Steatorrhoea or malabsorption	✔