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Clinicopathological Study of Upper GI Malignancy in 
Tertiary Care Centre of Nepal

Journal of College of Medical Sciences-Nepal, Vol-18, No 4, Oct-Dec 2022
ISSN: 2091-0657 (Print); 2091-0673 (Online) Open Access 

DOI: 10.3126/jcmsn.v18i4.48924

Ajay Kumar Gautam,1 Khus Raj Dewan,1 Bhanumati Saikia Patowary1
1Department of Gastroenterology, College of Medical Sciences Teaching Hospital, Bharatpur, Chitwan, Nepal.

Original Research Article

Correspondence: Dr. Ajay Kumar Gautam, Department of Gastroenterology, College of Medical Sciences-Teaching 
Hospital, Bharatpur, Chitwan, Nepal. Email: himaliphul@gmail.com. Phone: +977-9841352924.

ABSTRACT

Introduction

Upper gastrointestinal malignancies are among the most common causes for cancer related 
morbidity and mortality. These cancers rapidly progress to advanced stages even in the absence 
of significant symptoms, thus leading to delayed diagnosis and dismal prognosis. The aim of 
this study was to determine the prevalence, type and clinicopathological characteristics of upper 
gastrointestinal tumors.

Methods

This was a three year cross-sectional study involving 66 patients of upper gastrointestinal cancer. 
The study was conducted from March 2018 to February 2021 at the college of medical sciences-
Teaching Hospital, Nepal. Relevant clinical information, Endoscopic pattern and histological 
characterization were recorded. SPSS version 25.0 was applied for statistical analysis. 

Results

Total 66 patients were enrolled into this study. The mean age of the population was 59.13± 13.38 
years with male predominance (M:F-1.36:1). Common presenting symptoms were abdominal pain 
(76%), significant weight loss (61%), vomiting (40%). About 77% of the tumors were located in 
the stomach, 17% in the esophagus and 6% in the first and second part of the duodenum.  Most 
common endoscopic pattern of upper gastrointestinal lesion was ulceroproliferative type (53%).
Tissue histology showed adenocarcinoma as the commonest histological pattern with 82% followed 
by squamous cell carcinoma 10%.

Conclusions 

These malignancies can rapidly progress to advanced stages even in the absence of serious 
symptoms and endoscopy is needed in suspected patients to avoid delayed diagnosis and improve 
the disease outcome. 

Keywords: upper gastrointestinal malignancies; histopathological types; endoscopy.



JCMS | Vol-18 | No 4 | Oct-Dec 2022322

INTRODUCTION 

GI malignancies constitute one of the major 
tumor burdens to world and are among the most 
lethal of all malignancies.1 Malignant tumors of 
the oesophagus are one of the commonest types 
of cancer (sixth and ninth among cancers in men 
and women).2 Gastric cancers are the commonest 
upper gastrointestinal (UGI) malignancy and are 
the second most common cause of cancer related 
death worldwide.3

Despite advances in diagnosis and treatment, 
gastrointestinal (GI) malignancies are known 
for frequently progressing to advanced stages 
even in the absence of serious symptoms, 
thus leading to delayed diagnoses and dismal 
prognoses.4 Since there are very few studies 
in Nepal regarding upper gastrointestinal 
malignancies, this study is being conducted 
on such patients presenting to the College of 
Medical Sciences and Teaching Hospital, Nepal 
to study prevalence, clinical features as well as 
endoscopic and histological patterns.

METHODS 

This was a three year cross–sectional study 
involving 66 patients with upper gastrointestinal 
tumor. The study was conducted from March 
2018 to February 2021 at the college of medical 
sciences-Teaching Hospital,Bharatpur,Nepal. 
Relevant clinical information such as age, 
gender, clinical presentations (like unexplained 
recent weight loss, abdominal pain or swelling, 
dysphagia, haematemesis or melaena and 
anaemia), smoking history, alcohol use, spices 
were obtained from the patients. Upper GI 
Endoscopy was performed in all the patients 
with Pentax EPK 700 model / Sonoscape HD 
500 endoscope under 10% xylocaine anaesthetic 
spray of the oropharynx. The locations of 
the tumor were determined and recorded. 
Endoscopically lesions were classified as 
ulcerative, ulceroproliferative, polypoid and 

other types. Tissue biopsies were taken from the 
suspected lesions for histological confirmation 
and characterization. The tumors were classified 
by the predominant histological appearance 
into oesophageal squamous cell carcinoma/
adenocarcinoma or gastric squamous cell 
carcinoma/adenocarcinoma, Lymphoma or 
GIST. Further categorizations into differentiated, 
moderately differentiated, undifferentiated or 
poorly differentiated carcinomas were made.

An ethical clearance for this study was obtained 
from the Ethical and Research committee of 
College of Medical Sciences and Teaching 
Hospital, Bharatpur and all the patient’s written 
consent were obtained for the study.

Statistical analysis: Collected data were stored 
in an electronic database (MS- Excel Sheet). 
Statistical analysis was performed with statistical 
software (SPSS 25.0 for windows). Results were 
statistically analyzed using descriptive and chi 
square test.

RESULTS 

During the study period 66 patients of upper 
gastrointestinal malignancy were evaluated. 
The mean age of the study population was 59.13 
years ± 13.38 years (age ranged from 25 years 
to 88 years). Majority of patients (54.5%) were 
in the age group 60 years and above followed 
by age group 40-59 years (41%) and 18-39 years 
(4.5%).  50% male and 60% female were 60 years 
old and above.

Table 1. Distribution of the age (n = 66).

Age Group Total Percent

18-39 years 3 4.5%

40-59 years 27 41%

60 and above 36 54.5%

Total 66 100%

Mean age = 59.13 years ± 13.38; Minimum age = 
25 years, Maximum age = 88 years

Gautam et al. A Clinicopathological Study of Upper GI Malignancy in Tertiary Care Centre of Nepal



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Gautam et al. Clinicopathological Study of Upper GI Malignancy in Tertiary Care Centre of Nepal.

In this Study 38 (58%) males and 28 (42%) 
females. The male to female ratio was 1.36:1.

The risk factors identified in this study included; 
smoking in 35 (53%) cases which is followed by 
alcohol in 33 (50%) cases, with smoked meat 
consumer 16 (24%) and spicy meal taker 19 (29%). 
Whereas more than 1 risk factors were present in 
35 (53%) of cases.This study showed abdominal 
pain as a presenting symptom in 76 % of patients 
followed by significant weight loss in 61% of 
patients, vomiting (40%), loss of appetite in 46% 
of patients, along with melena (20%), dysphagia 
(15%), hematemesis (6%) and other symptoms 
(8%) including ascites, diarrhea etc. In this study, 
43 (64%) patients presented with anemia, 8 (12%) 
patients presented with abdominal lump and 
there were enlarged left supraclavicular lymph 
nodes in only 6 (9%) patients. Duration of illness 
was less than 3 months in 34(52%) cases and 
more than 3 months in 32 (48%) cases.

Majority of these tumors were located in the 
stomach (77%), followed by 17% in the esophagus 
and 6% in the duodenal. Of those located in the 
stomach, most common location was body of 
stomach with 26 (51%) cases, followed by 18 (35%) 
cases in antrum and 7 (14%) of cases in fundus. 
Within esophagus, middle 1/3rd was most common 
location with 7 (64%), followed by 4 (36%) in lower 

1/3rd of esophagus. In duodenal, 3 (75%) cases were 
seen in D1 and 1 (25%) case was in D2.

Table 3. showing frequency of upper GI cancer 
according to location (n=66).

Location Frequency Percent

Esophagus
Upper 1/3rd

Middle 1/3rd

Lower 1/3rd

Total 

0
7
4

11 (16.6%)

64%
36%

Stomach
Fundus
Body
Antrum
Total

7
26
18

51 (77.3%)

13.7%
51%

35.3%

Duodenum
D1
D2
Total 

3
1

4 (6.1%)

75%
25%

In this study most common macroscopic/gross 
appearance of cancer was ulceroproliferative 
type, which was seen in 35 (53%) cases, followed 
by 11 (16.6%) cases of ulcerative type, 4 (6%) 
cases of gastric outlet obstruction, 6 (9%) cases 
of protruding lesion, 7 (10.6%) cases of polypoid 
type, whereas other lesion types including 
fungating were seen in 3 (4.5%) cases. Among 

Table 2. Presentation of upper GI cancer according to location of lesion (n=66).

Signs/symptoms Oesophageal Cancer Stomach cancer Duodenal cancer Total p-value

Pain abdomen 2 45 3 50 0.020*

Weight loss 9 29 2 40 0.264

Vomiting 2 22 2 26 0.592

Loss of appetite 6 22 2 30 0.775

Melena 0 12 01 13 0.139

Dysphagia 9 1 0 10 <0.001

Hematemesis 1 3 0 4 0.463

Other symptoms 1 3 1 5 0.507

*p-value significant at level <0.05



JCMS | Vol-18 | No 4 | Oct-Dec 2022324

esophageal cancer 5 (45%) cases were ulcerative 
type and 6 (55%) cases was protruding lesion. 
Among Gastric cancer cases, 31 (60%) cases 
were ulceroproliferative type, 6 (11%) cases 
were ulcerative type, 4 (8%) cases were gastric 
outlet obstruction, 7 (13%) cases were polypoid 
type and other types lesion were seen in 4 (8%) 

cases, that includes fungating and infiltrative 
type. All 4 cases of duodenum (100%) were 
ulceroproliferative type.

During this study, total 48 cases of gastric and 
duodenal cancers were tested for Helicobacter 
pylori RUT (rapid urease test), 87% (42 cases) of 
the study population were positive for H.pylori. 

37 (79%) cases out of 43 cases of stomach cancer 
were positive for H. pylori, while all 4 cases of 
duodenal cancer were positive.

In our study, histologically most cases revealed 
adenocarcinoma 54 (82%), followed by 7 (10%) 
cases of squamous cell carcinoma, all of which 
belongs to esophageal carcinoma, 3 cases of 

GIST,1 case of carcinoid tumor, and 1 case of 
lymphoma. All 4 (100%) cases of duodenal 
carcinoma were adenocarcinoma, and 46 (90%) 
cases of gastric cancers were adenocarcinoma 
and among remaining 5 (10%) cases, 3 (5.8%) 
were gastrointestinal stromal tumor along with 
each carcinoid tumor and lymphoma. 

Gautam et al. Clinicopathological Study of Upper GI Malignancy in Tertiary Care Centre of Nepal

Figure 1. Bar diagram showing lesion types (Endoscopic appearance) of cancer in stomach (n=51).

Table 4. Association between biopsy findings and endoscopic location of different carcinomas.

Biopsy findings
Endoscopic location

p-value
Esophagus Stomach Duodenum

Adenocarcinoma 4 (6.1%) 46 (69.6%) 4 (6.1%)

0.010*
Squamous cell carcinoma 7 (10.6%) 0 (0%) 0 (0%)

Other types 0 (0%) 5 (7.6%) 0 (0%)

*p-value significant at <0.05



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Only 26 Gastric adenocarcinoma cases were sub 
classified, 10 (38%) were poorly differentiated, 
7 (27%) were moderately differentiated, 6 (23%) 
cases were signet ring cell carcinoma, 2 (7.7%) 
well differentiated and 1 (3.8%) undifferentiated.

Among all cases distant metastasis were observed 
in 7 (12%) cases. Intraabdominal lymph nodes 
were involved in 28 (48%) cases, among gastric 
cancers 26 (53%) were involved with nodal 
metastasis, 2(18%) in case of esophageal cancer 
and 1(25%) in case of duodenal cancer.

DISCUSSION 

Cancer incidence in general and GI cancer in 
particular varies widely in different parts of 
the world in different age groups. Studies from 
Nepal showed higher incidence compared to 
other parts of the world.5,6 

In this study of 66 patients of upper GI 
malignancy, upper GI malignancy were seen 
more commonly in the male gender compared 
to the female counter part (1.36:1), the average 
age of patient was 59 years and peaked between 
60 year and above age group (54.5%). Gastric 
carcinoma is extremely rare before the age of 30 
years and most patients are above 50 years of 
age.7,8 

There was a spectrum of median age incidence 
reported in different parts of the world. In the 
western world, it was 71 years in the USA, which 
is higher than this study. In Asian countries, 
median ages in different countries were low.  
Similar to this study was seen in Japan (61 
years).9  in TUTH Nepal (59.6±12.4 years),17 in 
western region Nepal (age group 51-70 years)10  
Contrast to this study, in Pakistan (48 ± 4.47 
years) and Saudi Arabia (47 years) incidence of 
cancer in early age population were seen.11,12 

Compared to this study, male: female ratio was 
higher in Mizoram (2.7: 1)13 In Nigeria (2.5:1),14 
in Kashmir (3.3: 1)15 and in Saudi Arabia (2.2: 

1)12. Similar to this study was seen in Pakistan 
(1.5: 1)16, in western region Nepal (1.8:1)10 and 
TUTH Nepal (2:1)17  Presumably, this male 
preponderance could be attributed to the high 
incidence of risk factors in male (like; smoking 
>60%, alcohol >50%), with male to female 
smoking ratio of 1.7:1 in this study).

Majority of patients (53%) in this study had 
a history of smoking, and 50% with history of 
alcohol intake, consumption of smoked meat 
were seen in 24% cases, along with spicy meal 
consumption in 29% cases. Similarly, in a study 
from Nigeria Ajayi et al.14 identified Alcohol, 
smoking and spices are the three main risk 
factors for upper GI malignancy. Study from 
north eastern India showed overwhelming 
majority of patients (77.8%) had a history of 
consumption of smoked meat, and 67.7% of 
patients had history of consumption of dried, 
fermented fish, and smoking history in 67.6% of 
males and 44% of females.18 Another study from 
Nepal also reported smoked meat, alcohol and 
smoking were associated with gastric cancer in 
more than 50% of cases (western region Nepal).10

Current study showed, dysphagia (82%) 
and weight loss (82%) were most common 
presentation of esophageal caarcinoma, in 
keeping up with the many studies as Dysphagia 
(86%) was reported as the most common 
presenting complaint of esophageal carcinoma 
by Durrani et al.16 and study by Ajayi et al.14 also 
reported similar stats. In Nepal, Thakur et al 
reported dysphagia was presenting complain in 
98.5 % of cases of esophageal carcinoma.19

Most of our patients with gastric cancer presented 
with abdominal pain (88%), weight loss (57%), 
vomiting (43%), loss of appetite (%) and melena 
(57%), which is similar to many studies, Barad 
et al.18, Durrani et al.16, Ajayi et al.14 In Nepali 
context Shah et al.17, revealed pain abdomen 
(87%), anorexia (81%), and weight loss (77%) 

Gautam et al. Clinicopathological Study of Upper GI Malignancy in Tertiary Care Centre of Nepal.



JCMS | Vol-18 | No 4 | Oct-Dec 2022326

which is very similar to our results. 51.9% of the 
patients in this study presented at the hospital 
within 3 months of the onset of symptoms while 
the only less than 15% presented after 6 months. 

In this study, most common presenting 
Symptom of upper GI malignancy noted was 
abdominal pain (75%), followed by weight loss 
(60%), vomiting (39%), loss of appetite (45%) 
and melena in 19% of cases. Similar to our study, 
abdominal pain was most common presentation 
in Nigeria (Ajayi et al.)14 64% of cases with 
anemia on presenting symptom was higher in 
our study than only 2.6% of anemia in same 
study, whereas abdominal lump was present in 
only 12% of cases in our study, which is lower 
than 30.8% reported by Ajayi et al.14 

The prevalence of oesophageal malignancies 
in this study was low (16%) in keeping with a 
similar study from Nigeria where oesophageal 
carcinoma were present in 16.6% of upper 
gastrointestinal tumors. Contrast to our study, 
Durrani et al.16 reported higher incidence (43.3%) 
of esophageal cancer, which also included cases 
of upper GI cancers. Other studies from Nepal 
also reported lower incidence, where incidence 
ranges from 1.6% to 10.7%.6,20

Gastric malignancies are important cause of 
mortality from cancer and one of the most deadly 
malignant neoplasm worldwide and in Nepal. 
The prevalence of gastric malignancies in this 
study was quite high (77%). Which is comparable 
to similar studies, in Nigeria by A. Ajayi et 
al.(67.9%),14 in Punjab by Durrani et al.(57.6%)16 
The incidence of stomach cancer is said to be 
highest in Japan, China, South America and the 
Eastern Europe. The high prevalence obtained 
here was in sharp contrast to 13.3% recorded in 
Nigeria by Atoba et al.21, 12% recorded in Lagos 
by Abdulkareem et al.,2 and 4.6% in maharastra 
by Khatib et al.22 In Nepal the incidence of 
gastric carcinoma recorded ranges from 4% to 

15.1%.6,20 The prevalence of duodenal carcinoma 
in this study was extremely low (6%), which is 
comparable to low incidence reported in Nigeria 
in similar study population by Ajayi et al.14

In this study, most common site for esophageal 
cancer was middle one third (64%) followed 
by lower third (36%). Our findings are similar 
to many other studies where middle third 
was commonest site followed by lower third. 
Mchembe et al.23, Kuwano et al.24, Ajayi et al.14 
and Durrani et al.16 Contrast to our study, in 
Kashmir by Mustafa et al.25 reported distal 
third (45%) as the most common site followed 
by middle (34.8%). Similar finding of distal 
esophagus as a commonest site of esophageal 
cancer was reported in Nepal by Pun et al.5 

Among esophageal cancers, in our study most 
common endoscopic/macroscopic appearance 
of cancer were protruding lesion (55%) and 
50% cases of ulcerative lesions. As only few 
studies mentioned esophageal gross lesion, in 
Tanzania by Mchembe et al.(2013),23 unlike this 
study, most common macroscopic appearance 
of esophageal cancer was ulcerative type 132 
(40.3%) ,similar finding were seen by Mustafa 
et al.(2016),25 who reported localized ulcerative 
lesion as the most common appearance (50%) 
followed by protruding lesion (19%)

Similary in Nepal, Pun et al. (2012)5 reported 
gross findings in squamous cell carcinoma were 
either exophytic or ulcerative lesion with deep 
irregular ulcers.

Unlike western countries,In Asia still 
Oesophageal squamous cell carcinoma (OSCA) is 
the predominant histologic type of oesophageal 
malignancy, in Iran by Pedram et al.26 reported 
81.3% cases of squamous cell carcinoma, 16.3% 
cases of adenocarcinoma, in japan Kuwano et 
al.24 also reported esophageal squamous cell 
carcinoma as commonest histological type 
with 91.6 %, in India by Cherian et al. also 

Gautam et al. Clinicopathological Study of Upper GI Malignancy in Tertiary Care Centre of Nepal.



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Gautam et al. Clinicopathological Study of Upper GI Malignancy in Tertiary Care Centre of Nepal.

reported similar findings as squamous cell 
carcinoma were seen in 92%. Among very few 
studies done in Nepal, Pun et al.5a total of 
106 cases of esophageal cancer were received 
in the department of pathology, BP Koirala 
Memorial Cancer Hospital. Relevant clinical 
data were retrieved from computer database 
of the hospital.Results: A total of 106 cases of 
esophageal carcinomas were diagnosed during 
a three years period. There were 68 (64.15% also 
reported similar study as 64 % of squamous 
cell carcinoma. This study showed 64% cases of 
esophageal adenocarcinoma, which is contrast to 
the many Asian studies mentioned above, may 
reflect small study sample or changing trend of 
cancer pattern in our part of the world due to 
increase in risk factors that are associated with 
the occurrence of esophageal adenocarcinoma. 
As reports from Asian countries have also shown 
a decline in incidence of SCC. Similar to study 
by Pun et al.5 where the maximum number of 
SCC were seen in middle esophagus and the 
maximum number of adenocarcinoma was seen 
in distal esophagus, our study also showed all 
squamous cell carcinoma in middle third and 
maximum number of adenocarcinoma in distal 
esophagus followed by middle esophagus.

Unlike in the USA where proximal stomach is 
the commonest site of cancer in stomach, in this 
study, distal part including body of stomach 
(51%) and antrum (35%) were common site 
followed by fundus (17%). Similarly, in Nigeria 
by Ajayi et al. (2016)14 62.3% were in the antrum 
while 37.7% were in the corpus. Likewise, Barad 
et al.18 in India, the most common site of gastric 
cancer was antrum (50.6%). in Nepal antrum 
was the commonest site of involvement (70%) by 
Gosh A et al. (2010)10, lower third of stomach was 
common site for gastric cancer (61.5%) followed 
by middle third (20%) and upper third (15%) 
Sah et al.(2015).17 

In this study, 60% of gastric lesions were 

ulceroproliferative type, 11% ulcerative type, 8% 
gastric outlet obstruction. Similar to our study 
Qureshi et al. showed 35.5% ulceroproliferative, 
26% proliferative, 31% ulcerative, and 7.4% 
infiltrative lesions in Kashmiri patients.15 Shaha 
A et al.11, Ulcerative lesion was 57.8% followed by 
ulceroproliferative lesion 24.9% and polypoidal 
lesion 17.3%. Another study done by Kabir et 
al.27 showed that ulcerative lesion was 56%, 
ulceroproliferative lesion 10%, and polypoidal 
lesion 34%.Unlike our report, Ghosh A et al.10 
reported type IV (40%) as most common gastric 
cancer in Nepal, followed by type III (33%) and 
type II (27%)

In this study, histologically majority (82%) 
were found to be adenocarcinoma consistent 
with other studies, Ajayi et al.14 reported 83 
% as adenocarcinoma, Barad et al.18 95.6% 
adenocarcinoma, in Nepal Ghosh A et al.10 
reported 100% adenocarcinoma, Sah et al.17 also 
showed 100% adenocarcinoma. Majority of the 
tumours in our study were poorly differentiated 
and moderately differentiated, similar to other 
studies (Ghosh et al.10, Barad et al.18). 

In this study, 12% had distant metastasis and 
majority (48%) had locally advanced gastric 
cancers at the time of presentation. This figure 
is higher to 9-17% seen in western countries 
and much higher to the prevalence of Japan 
where mass screening programmes for gastric 
cancer are in place. These studies suggest that 
patients with gastric adenocarcinomas usually 
present with advanced disease unfavorable 
histopathology.

H. pylori positivity in this study for those with 
gastric cancer was 79% and 100% for duodenal 
cancer. This was significant statistically. In 
Bangladesh, Talukdar et al. showed that the 
prevalence of H. pylori was 66% out of 50 cases of 
gastric cancer.27  Kabir et al.27 showed prevalence 
of H. pylori in 71.8% of gastric cancer patients. 



JCMS | Vol-18 | No 4 | Oct-Dec 2022328

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Gautam et al. Clinicopathological Study of Upper GI Malignancy in Tertiary Care Centre of Nepal.

Ajayi et al.14 also showed 71.7% were positive for 
H.pylori in gastric cancer patients.

CONCLUSIONS 

Upper GI malignancy mainly gastric cancers 
are apparently predominant in our part of the 
world. In view of the fact that upper GI tumors 

can rapidly progress to advanced stages even 
in the absence of serious symptoms, early 
esophagogastroduodenoscopy is needed in 
high risk cases to avoid delayed diagnosis and 
improve the disease outcome.

Conflict of Interest: None.



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Citation: Gautam AK, Dewan KR, Patawary BS, Clinicopathological Study of Upper GI Malignancy in a Tertiary Care 
Centre of Nepal. JCMS Nepal. 2022; 18(4); 321-29.

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