Gastric Cancer

 Stomach cancer is an adenocarcinoma of the stomach wall.

 The prognosis is generally poor;
 Most cases of gastric cancer are discovered only after local invasion has advanced or
metastases are present
 Stomach cancer is the fourth most commonly occurring cancer in men and the
seventh most commonly occurring cancer in women.
 There were over 1 million new cases in 2018.
 The top 3 countries with the highest rates of stomach cancer in 2018 are South Korea,
Mongolia and Japan.

ETIOLOGY:
Diet:

 High in smoked, salted, or pickled foods

 Low in fruits and vegetables

Chronic inflammation of the stomach:

 H. Pylori infection
- H. Pylori is a gram- negative bacterium that causes chronic inflammation in the stomach and
duodenum and is a common contagious cause of ulcers worldwide.
-Invades the lining of the stomach producing a cytotoxin and can lead to ulcer formation.
 Pernicious anemia
- People who have had stomach surgery, pernicious anemia, or achlorhydria have a higher
risk of stomach cancer. Pernicious anemia is a severe decrease in red blood cells caused
when the stomach is not able to properly absorb vitamin B12.
- Certain cells in the stomach lining normally make a substance called intrinsic
factor (IF) that we need to absorb vitamin B12 from foods. People without enough IF may
end up with a vitamin B12 deficiency, which affects the body’s ability to make new red blood
cells and can cause other problems as well. This condition is called pernicious anemia. Along
with anemia (too few red blood cells), people with this disease have an increased risk of
stomach cancer.
 Smoking
 Achlorhydria (absence of hydrochloric acid in gastric secretions)
- Hydrochloric acid in the gastric juice breaks down the food and the digestive enzymes split
up the proteins.
- It also kills bacteria protecting your body from harmful microbes which can enter your body
in food.
 Gastric ulcers
- Gastric ulcers are open sores in the stomach that bacteria can easily infect.
- It causes mutations in the DNA and damages the cells of the stomach lining
- Prolonged inflammation can lead to chronic inflammation of the stomach and even stomach
cancer.
Clinical Manifestations
 Often spread to adjacent organs before any distressing symptoms occur.
 The clinical manifestations can include unexplained weight loss, early satiety,
indigestion, abdominal discomfort or pain, and signs and symptoms of anemia
 The person appears pale and weak and complains of fatigue, weakness, dizziness, and, in
extreme cases, shortness of breath.
 The stool may be positive for occult blood.
 Supraclavicular lymph nodes that are hard and enlarged suggest metastasis via the
thoracic duct.

 The presence of ascites is a poor prognostic sign

Symptoms of early disease Symptoms of progressive disease

 pain relieved by antacids  dyspepsia
 resemble those of benign ulcers  early satiety
 little disturbance of gastric function  weight loss
 abdominal pain
 loss or decrease in appetite
 bloating after meals
 nausea and vomiting
  symptoms similar to those of peptic
ulcer disease

Assessment and Diagnostic findings:

 Physical examination is usually not helpful in detecting the cancer because most early gastric
tumors are not palpable.
 Ascites and hepatomegaly (enlarged liver) may be apparent if the cancer cells have
metastasized to the liver.
 Sister Mary Joseph’s nodules: Indicates malignancy
 Esophagogastroduodenoscopy: Test of choice for Gastric Cancer
- Endoscopic ultrasound is an important tool to assess tumor depth and any lymph node
involvement
 Computed tomography (CT Scan): to assess for surgical resectability of the tumor before
surgery is scheduled.
 CT of the chest, abdomen and pelvis is valuable in staging gastric cancer.

Medical Management
 There is no successful treatment for gastric carcinoma except removal of the tumor.
o If the tumor can be removed while it is still localized to the stomach, the patient may
be cured.
o If the tumor has spread beyond the area that can be excised, cure is less likely.

Surgical Therapy
 The surgical intervention used in the treatment of stomach cancer may be the same
surgical procedures used for PUD.
 When the lesion is located in the fundus, a total gastrectomy with esophagojejunostomy
is performed
 Lesions located in the antrum or the pyloric region are generally treated by either a
Billroth I or Billroth II
1. Pylorus is removed and the distal stomach is anastomosed directly to the duodenum)
2. Procedure partial gastrectomy (removal of the stomach) is performed and the cut end of
the stomach is closed.
 When metastasis has occurred to adjacent organs, such as the spleen, ovaries, or bowel,
the surgical procedure is modified and extended as necessary.

Adjuvant Therapy
 Chemotherapy
 Radiation therapy
 The patient with a tumor that is deemed resectable undergoes an open surgical procedure
to resect the tumor and appropriate lymph nodes.
 The patient with an unresectable tumor and advanced disease undergoes chemotherapy.
 A total gastrectomy may be performed for a resectable cancer in the midportion or body
of the stomach. (The entire stomach is removed along with the duodenum, the lower
portion of the esophagus, supporting mesentery, and lymph nodes)
 Reconstruction of the GI tract is performed by anastomosing the end of the jejunum to
the end of the esophagus, a procedure called an esophagojejunostomy

 A radical subtotal gastrectomy is performed for a resectable tumor in the middle and
distal portions of the stomach.
 A proximal subtotal gastrectomy may be performed for a resectable tumor located in the
proximal portion of the stomach
 A total gastrectomy or an esophagogastrectomy is usually performed in place of this
procedure to achieve a more extensive resection.
 Common problems of advanced gastric cancer that often require surgery include
pyloric obstruction, bleeding, and severe pain.
  Gastric perforation is an emergency situation requiring surgical intervention

Pallative
 A gastric resection may be the most effective palliative procedure for advanced gastric
cancer.
 Palliative procedures such as gastric or esophageal bypass, gastrostomy, or jejunostomy
may temporarily alleviate symptoms
 Palliative rather than radical surgery may be performed if there is metastasis to other vital
organs
 If surgical treatment does not offer cure, treatment with chemotherapy may offer further
control of the disease or palliation.
  Commonly use single-agent chemotherapeutic medications

Gastric Surgery:
 Performed on patients with peptic ulcers who have life threatening hemorrhage, obstruction,
perforation or penetration or whose condition does not respond to medication.
 Indicated for patients with gastric cancer or trauma.

Vagotomy:
Is the surgical cutting of the vagus nerve to reduce acid secretion in the stomach.
Purpose: The vagus nerve trunk splits into branches that go to different parts of the stomach. Stimulation
from these branches causes the stomach to produce acid. Too much stomach acid leads to ulcers that may
eventually bleed and create an emergency.

Pyloroplasty:

A surgical procedure in which the pylorus valve at the lower portion of the stomach is cut and resutured,
relaxing and widening its muscular opening (pyloric sphincter) into the duodenum (first part of the small
intestine)
The pylorus is a thick, muscular area. When it thickens, food cannot pass through.
Cause: Unknown, but genetic and environmental factors might play a role. 

Partial Gastrectomy:
  A partial gastrectomy is a surgical procedure that is performed to remove a portion of the
stomach to treat stomach cancer and benign stomach tumors.
 When a partial gastrectomy is used as a treatment for stomach cancer, it is performed by a
surgical oncologist (a surgeon who specializes in treating cancer)
Total Gastrectomy:

 Doctors remove the entire stomach, surrounding lymph nodes and fatty tissue. Next, the surgical
team connects the esophagus to the intestines.
 A surgeon may create a new “stomach,” or pouch, by folding over a portion of the intestines, to
allow for more effective digestion.

Nursing Management:

 Assess the family’s knowledge of preoperative and post-operative surgical routines and rationale
for surgery:
o Assess for the presence of bowel sounds
o Palpate the abdomen to detect masses and tenderness
 After surgery:
o Assess for complications secondary to surgical intervention such as:
- Hemorrhage
- Infection
- Abdominal distention
- Atelectasis
- Impaired nutritional status

Increased risk for:

 Hemorrhage
 Dietary deficiencies
 Bile reflux
 Dumping syndrome

Reducing Anxiety
 The nurse encourages the patient to verbalize fears and concerns and answers the
patient’s and family’s questions.
 If the patient has an acute obstruction, a perforated bowel, or an active GI hemorrhage,
adequate psychological preparation may not be possible.

Relieving Pain After surgery

 Analgesic agents may be administered as prescribed to relieve pain and discomfort.
 Provide adequate pain relief so the patient can perform pulmonary care activities

Promoting Optimal Nutrition

  Encourage the patient to eat small, frequent portions of nonirritating foods to decrease gastric
irritation.
 Food supplements should be high in calories, as well as vitamins A and C and iron,
 Parenteral nutrition may be necessary.
 Because the patient may develop dumping syndrome when enteral feeding resumes after
gastric resection, the nurse explains ways to prevent and manage it
 If a total gastrectomy is performed, injection of vitamin B12 will be required for life,
 The nurse monitors the IV therapy and nutritional status and records intake, output, and daily
weights to ensure that the patient is maintaining or gaining weight.
 The nurse assesses for signs of dehydration and reviews the results of daily laboratory studies to
note any metabolic abnormalities
 Antiemetics are administered as prescribed.

Providing Psychosocial Support

 The nurse helps the patient express fears, concerns, and grief about the diagnosis.
 It is important to answer the patient’s questions honestly and to encourage the patient to
participate in treatment decisions
 Recognize mood swings and defense mechanisms
 Project an empathetic attitude and spends time with the patient.

Recognizing Obstacles to Adequate Nutrition:

Dysphagia and Gastric Retention

 Dysphagia
o May occur in patients who have had a truncal vagotomy,
 Gastric retention
o May be evidenced by abdominal distention, nausea, and vomiting.
o Regurgitation may also occur if the patient has eaten too much or too quickly.
o If gastric retention occurs, it may be necessary to reinstate NPO status and NG
suction

Bile Reflux

 Bile reflux gastritis and esophagitis may occur with the removal of the pylorus, which
acts as a barrier to the reflux of duodenal contents.
o Burning epigastric pain and vomiting of bilious material manifest this condition.
o Eating or vomiting does not relieve the situation.
 Agents that bind with bile acid
Dumping Syndrome:

 As an unpleasant set of vasomotor and GI symptoms that sometimes occur in patients who have
had gastric surgery or a form of vagotomy.
 Foods high in carbohydrates and electrolytes must be diluted in the jejunum before absorption
can take place, but the passage of food from the stomach remnant into the jejunum is too rapid
to allow this to happen.
 The hypertonic intestinal contents draw extracellular fluid from the circulating blood volume
into the jejunum to dilute the high concentration of electrolytes and sugars.
 The ingestion of fluid at mealtime also causes the stomach contents to empty rapidly into the
jejunum

Early symptoms include:

 Sensation of fullness
 Weakness
 Faintness
 Dizziness
 Palpitations
 Diaphoresis
 Cramping pain
 Diarrhea

Anorexia may also be a result of the dumping syndrome because the person may be reluctant to
eat.

Steatorrhea also may occur in the patient with gastric surgery.

- It is partially the result of rapid gastric emptying, which prevents adequate mixing with
pancreatic and biliary secretions. In mild cases, reducing the intake of fat and administering
an antimotility medication (eg, loperamide [Imodium]) may control steatorrhea.

Vitamin and Mineral Deficiencies:

 Other dietary deficiencies that the nurse should be aware of include malabsorption of
organic iron, which may require supplementation with oral or parenteral iron, and a low
serum level of vitamin B12, which may require supplementation by the intramuscular route.
 Total gastrectomy results in lack of intrinsic factor, a gastric secretion required for the
absorption of vitamin B12 from the GI tract. Unless this vitamin is supplied by parenteral
injection after gastrectomy, the patient inevitably suffers vitamin B12 deficiency, which
eventually leads to a condition identical to pernicious anemia.

Teaching Dietary Self-Management

The following teaching points are emphasized:
 To delay stomach emptying and dumping syndrome, the patient should assume a low
Fowler’s position during mealtime and then remain in that position for 20 to 30 minutes.
 Antispasmodics, as prescribed, also may aid in delaying the emptying of the stomach.
 Fluid intake with meals is discouraged; instead, fluids may be consumed up to 1 hour
before or 1 hour after mealtime.
 Meals should contain more dry items than liquid items.

Monitoring and Managing Potential Complications

Hemorrhage complicates gastric surgery

 Usual signs of rapid blood loss

 May vomit considerable amounts of bright red blood.
 Assess NG drainage for type and amount. Some bloody drainage for the first 12 hours is
expected, but excessive bleeding should be reported.
 Assess the abdominal dressing bleeding.

Perform emergency measures such as:

 NG lavage
 Administration of blood and blood products along with hemodynamic monitoring

Duodenal Tumor
 Tumors of the duodenum are uncommon and are usually benign and asymptomatic.
 Malignant tumors are more likely to cause specific signs and symptoms leading to
diagnosis.
 The relative rarity of tumors of the duodenum and the nonspecific nature of their
manifestations complicate their diagnosis and treatment.

Clinical Manifestations
 Duodenal tumors often present insidiously with vague, nonspecific symptoms.

Symptomatic, benign tumors

 Often present with intermittent pain
 Next most common presentation is occult bleeding

Malignant tumors
 Sustained weight loss and are malnourished at diagnosis.
 Bleeding and pain are common.
 Perforation of the bowel occurs in approximately