MLACases

[Combined > Examinations > Abdomen] 

Suspected Upper Gastrointestinal Tract Cancer 2 (Liver) (NEW)

Task

Where are you: 

FY2 doctor in the GP surgery.

Who your patient is: 

David Bentley is a 60 year old man who has presented with weight loss. 

Other information you have about the patient: 

None. 

What you must do: 

Take a focused history, perform relevant examination and discuss management with the patient.

Patient Information

• You have been experiencing weight loss for the last 6 months.
• You've lost about 5kg without trying and noticed your clothes feeling much looser.
• You have lost your appetite and feel somewhat tired a lot of the time.
• No other symptoms reported: No headaches, weakness or fits. No hoarseness. No cough / haemoptysis, breathlessness or chest pain. No nausea, vomiting, difficulty swallowing, indigestion, jaundice, change in bowel habit, or blood in the stool. No urinary symptoms or blood in the urine. No muscle or joint pains. No unusual/recurrent bruising or infections. No lumps or bumps noticed. No recent low moods or anhedonia. No heat intolerance or excessive thirst.
• Otherwise previously fit and well: No previous medical or mental health problems. No medications. No family history of cancer or gastrointestinal conditions.
• ⁠Lifelong non-smoker. Moderate drinker (e.g. 12 units per week spread across 3 or more days). No recent foreign travel.
• You work an office job.
• Q - What could this be doctor?
• Q - What tests do I need?

Setup:

• An abdominal manikin is present in the room with an enlarged liver.

Examiners prompt:

• Basic observations are normal.
• On palpation of the abdomen, there is some tenderness in the right upper quadrant region.

Data Gathering

• GRIPS 2
  • Position - I understand that you've been experiencing some weight loss.
  • Presenting Complaint - Could you take me through everything that's been happening?

Note:

Cancer Research UK [Managing non-specific symptoms in primary care]:–

"Less than 50% of patients that go on to be diagnosed with cancer initially presented to primary care with ‘red flag’ symptoms (i.e. typical site-specific symptoms that are known to have a high risk of cancer e.g. a breast lump). 

More commonly, people present with unexplained, non-specific signs and symptoms such as: 

• unexplained weight loss 
• fatigue 
• abdominal symptoms (pain, bloating) 
• nausea or vomiting, loss of appetite 
• non-specific pain such as bone pain
• unexplained abnormal test results - e.g. raised platelet count."
  

• Explore Weight Loss
  • Quantify - Do you know how much weight you have lost? Roughly how many kilos or clothes sizes have you gone down?
  • Timeframe - How long did it take for you to lose this much weight? Is it ongoing or stabilising?
  • Intent - And just to double check... Have you intentionally tried to lose any weight during this time?
  • Appetite - How’s your appetite been? Any change in what or how much you eat? Do you feel full quickly or just not fancy eating?
  • Associated symptoms - Anything else you've noticed alongside this loss of weight and appetite?...
    • Constitutional symptoms (Rest of FLAWS)
      • Any fevers, tiredness, loss of energy or sweats (particularly at night) or lumps or bumps anywhere in the body?

Note:

NICE NG12 [Suspected Cancer: Recognition and Referral: Non-Site-Specific Symptoms]:–

"For people with unexplained weight loss, which is a symptom of several cancers including colorectal, gastro-oesophageal, lung, prostate, pancreatic and urological cancer:

• carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely and
• offer urgent investigation or a suspected cancer pathway referral."
  

• Systems Review (To localise a possible cancer site and/or to screen for other causes for their weight loss)
  • Neurological
    • Any new or persistent headaches, vomiting, problems with your vision, balance, or coordination?
    • Any weakness, numbness, or tingling in any parts of your body?
    • Any episodes of fits, confusion, memory loss, or personality changes?
  • ENT
    • Any changes in your sense of hearing, smell or taste?
    • Any mouth ulcers, hoarseness or persistent sore throat?
  • Cardiorespiratory
    • Have you had any chest pain, palpitations or irregular heartbeats, dizziness or ankle swelling?
    • Any shortness of breath or wheezing? e.g. when walking or lying flat?
    • Have you noticed any cough? Have you coughed up phlegm or any blood?
    • Any recent chest infections or travel abroad?
  • Gastrointestinal
    • Any nausea, vomiting, difficulty swallowing, indigestion, heartburn, abdominal pain, discomfort or swelling?
    • Any yellowing of the skin or eyes? Change in stool colour (pale) or urine (dark)?
    • Any changes in your bowel habits such as diarrhoea or constipation? Any blood in the stool or black/tarry stools?
  • Genitourinary
    • Any blood or darkening of your urine recently?
    • Any changes in how you pass urine, for example – more frequent (especially at night), urgency, or any accidents? 
      
    • Any difficulty starting or stopping your stream, or dribbling afterwards?
    • Any changes in your sexual function or interest?
    • Any pain in your back or sides?
  • Musculoskeletal
    • Any new bone pains, joint swellings or stiffness?
  • Haematological / Lymphatic
    • Have you been getting more tired or run down, or noticed any unusual or repeated bruises, nosebleeds or infections?
    • Any lumps or swellings in your neck, armpits, or groin?
    • Any night sweats?
  • Endocrine
    • Have you felt excessively thirsty or passed urine more often than usual?
    • Have you been feeling unusually hot, sweaty, or shaky?
    • Have you noticed your heart racing or tremor in your hands?
  • Psychiatric
    • Any stressful life events, low mood, lack of interest, or anxiety recently?

Note:

BMJ Best Practice [Assessment of Unintentional Weight Loss] – "The differential diagnosis is extremely broad. In case series, the most common aetiologies are: malignancy, gastrointestinal conditions and psychiatric causes. Other aetiologies that should be considered include: cachexia syndromes associated with organ failure, endocrinopathies, serious infections, medication adverse effects, substance misuse and social factors that prevent adequate access to foods."

• Differential Diagnosis

Note:

NHS UK [Genomics Education: Family history in clinic] – “Take an accurate family history. Focus on the age of any cancer diagnosis in relatives, the sites of tumours, and any presence of multiple cancers (including bilateral disease)."

• PMAF
  • Past Medical History
    • Do you have any long-term medical conditions or anything you’ve been treated for in the past?
      • Just to check... so no major health issues like diabetes, heart or lung conditions, digestive, stomach or bowel problems, mental health problems?
  • Medication History & Allergies
    • Do you take any regular medications at the moment - including things from your GP, over-the-counter, or herbal remedies?
      • So you haven't started or stopped any medicines around the time this weight loss began?
    • Do you have any allergies to medicines or anything else?
  • Family History
    • Has anyone in your family had any serious medical problems such as cancer?
      • → If yes: Which type and at what age were they diagnosed?
        

Note:

Cancer Research UK [Smoking and cancer] – "Smoking is the biggest cause of cancer in the UK and causes at least 16 different cancer types."

Cancer Research UK [Alcohol and cancer] – "Drinking alcohol causes 7 different types of cancer."

Cancer Research UK [HP stats: Bowel cancer risk factors] – “28% of bowel cancer cases in the UK are caused by eating too little fibre.”

ORR UK [Occupational Health: Occupational cancers] – "Occupational cancers are often caused by prolonged exposure over many years to carcinogens in the workplace, not only to chemical substances such as dust and fumes, but also from exposures to the sun and from shift work for example."

• Social
  • Life Habits
    • Smoking – Do you smoke or have you ever smoked?
      • → If yes: How many a day and for how long?
    • Alcohol – Do you drink alcohol at all?
      • → If yes: Roughly how much would you say you drink in a typical week? ...Over how many days do you drink that?
    • Diet – How would you describe your usual diet? How is your intake of fruit and vegetables?
    • Stressors – Have you been under any particular stress in recent months?
  • Life Situation
    • Home – Do you live with anyone at home? Do you have any specific needs or responsibilities that may impact your ability to attend healthcare appointments?
    • Work – Are you currently working?
      • What is/was your line of work?
      • Have you ever worked, in any kind of job or industry where you might have been exposed to dust, chemicals, radiation (including sun exposure) or any other substances that could affect your health?
        • → If yes: determine the nature of the substances and the duration of the exposure.
    • Travel – Have you travelled anywhere abroad in recent months?

Note:

GMC [Decision making and consent] – "You must seek to explore your patient's needs, values and priorities, their concerns and their expectations about what treatment or care could achieve."

• ICE
  • Ideas – Have you had any thoughts as to why you think might be causing this weight loss?
  • Concerns – Is there anything specific that’s worrying you the most about it?
  • Expectations – What were you hoping I could do for you today?

Note:

BMJ Best Practice [Assessment of unintentional weight loss] – “A thorough physical examination is essential to look for signs of malignancy, chronic infection, endocrine or systemic disease, and to assess the degree of nutritional loss.”

RCGP [Clinical Skills Handbook] – “In a patient presenting with unexplained weight loss, assess for hepatomegaly, splenomegaly or other abdominal masses, and look for lymphadenopathy, cachexia or oral lesions that may suggest malignancy or systemic disease.”

• Physical Examination
  • 1) Verbalise overview of all examinations (briefly)
    • Thank you for answering my questions, David. I'd now like to examine you...
    • Basic Observations - Weight, BP, HR, O2 sats, RR, Temp.
      • I'd like to take all of your basic observations, including your weight, blood pressure, heart rate, breathing rate and others.
    • Specific examinations (systems / body parts) - General appearance, hands, eyes, mouth, neck, chest, CVS, abdomen, legs.
      • I’d then like to do a thorough general physical examination, looking at your overall appearance and colour; your hands, eyes and inside the mouth; feeling the glands in your neck and underarms; listening to your chest and heart; and examining your tummy and legs.
    • Bedside tests - 12-lead ECG, Capillary glucose, Urine dipstick.
      • I'd also like to do some bedside tests including a tracing of your heart, a finger prick to check your blood sugar and a urine sample for a urine dip test.
      • Would that be okay?
  • 2) Introduce abdominal exam to perform
    • Explain & Get Consent - I'd now like to examine your tummy. This will involve having a look, feel, tap and listen to your tummy. Would that be okay? Are you happy for me to proceed?
    • Chaperone - I'd like to request a male chaperone to be present during the examination.
    • Exposure & Positioning - If you don't mind exposing from your waist upwards and lying flat on the couch.
  • 3) Perform abdominal exam (giving a running commentary)
    • Ok we'll begin the examination now...
    • Inspection
      • For distention, swellings, scars, dilated veins, bruising. I’m just having a look at your tummy first… no obvious swelling, scars, dilated veins or bruising.
    • Palpation
      • Superficial → For tenderness and superficial/large masses. I’m now going to feel your tummy…are you experiencing any discomfort anywhere at the moment? Great. I'm feeling your tummy now...any pain or discomfort so far? Okay I can see that there is some pain in the right upper quadrant of the tummy.
      • Deep → For deep masses, palpate liver (don't miss), spleen, ballot kidneys. I'm now going to press down a bit deeper this time, let me know if there's any pain. I'm now going to feel for your liver now to assess it's size. Deep breaths in and out for me please. Thank you very much. I can just feel the lower edge of your liver here several centimetres below your ribcage - it feels a little enlarged and is slightly tender.
    • Percussion
      • Liver span, free fluid. Now I’m tapping on your chest and tummy to assess the size of the liver and check for any fluid.
    • Auscultation
      • Listen for hepatic/epigastric bruits and bowel sounds. Almost done now. I'm now going to have a listen to your liver, stomach and bowels.
    • Thank you very much for bearing with me - that's the end of the examination. I'll leave you to get dressed.
    • Whenever you're ready, if you don't mind joining me back on the chair and we'll discuss the next steps.

Basic Observations → Normal

Abdominal examination → mild tenderness in RUQ, hepatomegaly (>2cm below right costal margin / liver span >12cm)

Management

Note:

Macleod's Clinical Examination [15th ed.] – “The liver span is normally 6–12 cm in the mid-clavicular line. Enlargement or tenderness should prompt assessment for hepatic pathology including malignancy or metastasis.”

• Impression - Unexplained weight loss with an enlarged tender liver, requiring further investigation (to assess for liver cancer/mets)
  • Suspected cancer approach (link) - air on the side of caution at this early stage and give a differential diagnosis that includes both benign and malignant causes.
    • Explain Findings - You've been experiencing unintentional weight loss for a few months without any other symptoms or any significant medical background. On examination, the liver was enlarged and a bit tender.
    • Give a DDx - There are a few possible things that could cause this kind of picture: it could be something benign like metabolic conditions affecting the liver such as non-alcoholic fatty liver disease, or certain infections or inflammation of the liver ...but it can also sometimes be caused by something more serious. More serious possibilities include a cancer of the liver or a spread of cancer to the liver from another part of the abdomen.
    • Explain concern - Since you've mentioned that the weight loss has persisted for 6 months, in your age group we have to always consider the possibility of cancer, and so I think it's really important we do some urgent investigations to get to the bottom of what's causing this. If it was cancer, getting treatment as early as possible could really make the difference.
    • Reiterate earliness - It's important to reiterate that it is very difficult to tell at this early stage what's causing this until we do some further investigations - particularly because your symptoms are quite vague and so it could be a number of different things.
• Management Plan

Key Themes (Overview):

• Offer Urgent Direct Access US of the Abdomen - To be performed within 2 weeks by a specialist; Explain what the US involves (simple, rapid test to look at the liver and surrounding structures).
• Additional Investigations in GP surgery - In the meantime arrange baseline bloods and urinalysis.
• If Scan is Suspicious, Refer Urgently - To MDT Cancer Team; Further Investigations (CT/MRI, specialist blood tests, biopsy); Treatment if confirmed.
• Aftercare (FSL) - Follow up to discuss results of the ultrasound and tests; Safety netting for delayed or missed appointments or for acute symptoms.

Note:

NICE NG12 [Suspected Cancer: Recognition and Referral: Non-Site-Specific Symptoms]:–

"For people with unexplained weight loss, which is a symptom of several cancers including colorectal, gastro-oesophageal, lung, prostate, pancreatic and urological cancer:

• carry out an assessment for additional symptoms, signs or findings that may help to clarify which cancer is most likely and
• offer urgent investigation or a suspected cancer pathway referral."

NICE [NG12: Suspected Cancer Recognition and Referral: Liver cancer]:–

Consider an urgent, direct access* ultrasound scan (to be done within 2 weeks) to assess for liver cancer in people with an upper abdominal mass consistent with an enlarged liver. 

*Direct access – This is when a person is referred directly by their GP for a test in a specialist service, and where the GP retains responsibility for the person's care, including following up and acting on the results.

• Offer Urgent Direct Access US of the Abdomen - To be performed within 2 weeks by a specialist; Explain what the US involves (simple, rapid test to look at the liver and surrounding structures); Results to be discussed with GP.
  • To be performed within 2 weeks by a specialist - The next step is to request an urgent direct-access ultrasound scan of your abdomen, which should be performed by a specialist within 2 weeks, in line with national guidance.
  • Explain what the US involves - This is so that they can look closely at your liver and surrounding structures to identify what’s causing the enlargement and tenderness. The scan is painless and takes about 15–20 minutes. A specialist will place a small probe on your tummy with some gel to create images on a monitor displaying your liver and nearby organs. It's similar to the scans used in pregnancy. There’s no radiation involved, and you can usually eat and drink normally unless told otherwise.
  • Results to be discussed with GP - The images are reviewed by the specialist, and a report will be sent directly back to us at the GP surgery usually within a few days. Once we have the results, we’ll meet again to discuss what they show and decide on the next steps.

Note:

RCGP [Clinical Skills Handbook] – “In primary care, unexplained weight loss should prompt baseline bloods and urine analysis while arranging appropriate imaging or referral.”

NICE CKS [Weight loss – unintentional] – “Initial investigations should include full blood count, renal and liver function, inflammatory markers, thyroid function and urinalysis as part of a general assessment.”

BMJ Best Practice [Assessment of unintentional weight loss] – “Basic investigations such as blood count, ESR/CRP, renal, liver, and thyroid function, and glucose are first-line to identify systemic disease.”

• Additional Investigations in GP surgery - In the meantime arrange baseline bloods and urinalysis.
  • In the meantime, I'd like to arrange some simple investigations here, including:
    • Baseline Bloods (FBC, LFTs, U&Es, TFTs, ESR, CRP, Glucose/HbA1c) - A full blood count to check for anaemia and signs of infection, liver function tests to check for inflammation or blockage in the liver, check your renal and thyroid function, CRP and ESR to check for inflammation in the body and glucose/HbA1c to check for diabetes.
    • Urinalysis - I'd like to take a urine sample to look for blood, protein, or glucose in your urine (if not already mentioned).

Note:

NICE NG12 [Suspected cancer: recognition and referral] – “Refer people using a suspected cancer pathway (for an appointment within 2 weeks) if investigation findings are consistent with possible cancer.”

Macmillan Professional Guidance [Pathways to diagnosis] – “Referral to a multidisciplinary cancer team ensures coordinated assessment and communication once cancer is suspected or confirmed.”

• If Scan is Suspicious, Refer Urgently - To MDT Cancer Team; Further Investigations (CT/MRI, specialist blood tests, biopsy); Treatment if confirmed.
  • To MDT Cancer Team - If the ultrasound or blood tests suggest that there’s something serious, such as a possible cancer, we’ll arrange for you to be seen urgently by a specialist hospital team. This team usually includes liver, digestive, and cancer specialists.
  • Further Investigations (CT/MRI, specialist blood tests, biopsy) who will review your scan and may carry out further tests. These tests help the specialists confirm exactly what’s happening and decide on the best treatment for you and include:
    • More detailed imaging (for example, a CT or MRI scan)
    • Specialised blood tests or tumour markers
    • Occasionally, a biopsy, which means taking a very small sample of tissue from the liver to look at under a microscope.
  • Treatment if confirmed - If it does turn out to be cancer, the next steps would depend on the type, size, and stage of the cancer, and whether it started in the liver or spread from somewhere else. Treatment might include options such as surgery, targeted medications, or radiotherapy.

Note:

NHS England [Faster Diagnosis Standard] – “Ensure clear communication of results and that the referring clinician remains responsible for acting on outcomes of direct access imaging.”

NICE NG12 [Suspected cancer: recognition and referral] – “Ensure that people are told how they will receive results, what further steps will follow, and that arrangements are in place for rapid review of abnormal results.”

RCGP [Clinical Skills Handbook] – “Safety-netting should include advising the patient when and how to seek help if symptoms worsen."

• Aftercare (FSL) - Follow up to discuss results of the ultrasound and tests; Safety netting for delayed or missed appointments or for acute symptoms.
  • Follow up - As soon as the test results and ultrasound report are available, we can arrange a follow-up appointment to go through everything and discuss the next steps.
  • Safety netting
    • Delayed or missed appointments
      • If you don’t receive an appointment letter to see the specialist within 1 week then let us know and we will chase up (expedite) the appointment for you.
      • If for whatever reason you miss your appointment, let us know as soon as possible so we can arrange another appointment for you. 
    • Acute symptoms - Please contact us urgently or go straight to A&E if you develop:
      • Yellowing of the skin or eyes (jaundice)
      • Vomiting blood or passing black stools
      • Severe or persistent abdominal pain
      • Sudden swelling of your tummy or legs

Lesson Summary

• 60-year-old man presents to GP with unintentional weight loss for 6 months with no other symptoms or significant medical or psychosocial history. On examination, there is an enlarged, mildly tender liver.
  

Data Gathering

• GRIPS
• Explore Weight Loss & Associated Symptoms
• Systems Review
• D/Ds (Unintentional Weight Loss)
  • Most common: malignancy, gastrointestinal conditions, psychiatric.
• PMAF
  • Screen for past medical problems, changes in medications and family history of cancer
• Social
  • Screen for other risk factors of cancer
• ICE
• Physical Examination (Abdominal manikin) → mildly tender hepatomegaly
  • Basic Observations
  • Specific Examinations
    • General appearance, hands, eyes, mouth, neck, chest, CVS, abdomen, legs.
  • Bedside tests
    

Management

• Impression
  • Unexplained weight loss with an enlarged tender liver, requiring further investigation (to assess for liver cancer/mets) 
    • Explain findings
    • Give D/Ds
    • Explain concern
    • Reiterate earliness
• Management Plan
  • Offer Urgent Direct Access US of the Abdomen
  • Additional Investigations in GP surgery
  • If Scan is Suspicious, Refer Urgently
  • Aftercare (FSL)
    • Follow up to discuss results; Safety netting