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10 Stomach
10 Stomach
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CLINICAL FEATURES
Risk factors
Environmental/ Precancerous lesions Genetic and familial
Genetic and familial
occupational/diet/habits
Smoking/alcohol/obesity H. pylori E-cadherin gene
Consuming red meat, infection, mutation in
smoked salmon fish, chronic gastritis diffuse cancers
cabbage, diet rich in Pernicious Mutation in
nitrosamines, lead anaemia APCgene for p-
Occupational-rubber/ coal Intestinal catenin in
workers metaplasia intestinal
Lower social status→distal Adenomatous cancers-50%
cancers polyps more Inactivation
Higher social than 2 cm tumour
status→proximal cancers Benign gastric suppressor gene
ulcer p53 in 30% cases
Previous gastric Loss of
surgery heterozygosity
Menetrier's in the BCL2
disease gene, an
inhibitor of
apoptosis
(intestinal type)
Blood group A
Clinical features
Symptoms
Asymptomatic in early gastric cancer or often in cancer of body of stomach.
Dyspepsia (any new onset of dyspepsia over the age of 45 should be
considered to be due to adenocarcinoma until proven otherwise).
Weight loss, anorexia, and lethargy.
Anaemia (iron deficiency due to chronic blood loss).
Occasionally presents as acute upper GI bleeding
Dysphagia uncommon unless involving the proximal fundus and gastro-
oesophageal junction.
Symptoms of Gastric outlet Obstruction(distal antral tumors)
ü Early satiety, bloating, indigestion, anorexia, nausea, vomiting,
epigastric pain, and weight loss.
ü Patients are frequently malnourished and dehydrated and have a
metabolic alkalosis, factors that increase operative
Upper abdominal pain with vague epigastric discomfort, constant nonradiating
pain which is not related to food intake.
Epigastric lump
Symptoms of metastatic disease
Occasionally carcinoma stomach can present as perforation
Signs
Features of gastric outlet obstruction
ü Visible Gastric Peristalsis
ü Auscultopercussion test + ve
ü +ve succussion splash
Mass in pylorus lies above the umbilicus, nodular, hard, with impaired
resonance, mobile, moves with respiration
In case of metastasis
ü +ve Troisier's sign.
ü liver may be palpable with secondaries which are hard, nodularwith
umbilication.
ü +ve rectovesical secondaries. (Blumer shelf) on per rectal examination.
ü + ve Trousseau sign-migrating thrombophlebitis
ü Secondaries in umbilicus, as Sister Joseph's nodules
Unusual presentations-acanthosis nigricans, Irish node in the left anterior
axillary region.
Diagnosis
Preoperative Preparation
ü Correction of anaemia, nutrition, fluid and electrolyte
ü Cardiac, respiratory and renal status assessment and optimization
ü Stomach wash using normal saline
ü Prophylactic antibiotic
ü Blood/FFP may be needed preoperatively and for surgery
Surgery
Early growth in Pylorus Lower radical gastrectomy with proximal
5 cm clearance is ( Subtotal gastrectomy),
along with removal of greater omentum,
lesser omentum,tail of pancreas (when
required)
D2 Clearance and later Billroth II
anastomosis.
Growth in the OG junction or upper part Total gastrectomy with lymph node
of the stomach Clearance
Growth in the body or linitis plastica total gastrectomy (radical) with
oesophagojejunal anastomosis
Recent Advance
v Endoscopic mucosa/ resection (EMR) in early gastric cancer.Tumour less than
2 cm, elevated, well-differentiated tumours without nodal disease is the ideal
selection for EM.
v Photodynamic therapy
Adjuvant Therapy
Chemotherapy Chemoradiotherapy lmmunochemotherapy
FAM regime is 5- Postoperative It is given in stage Ill
fluorouracil, adriamycin, radiotherapy (RT) with carcinoma after radical
mitomycin C chemotherapy using 5 FU gastrectomy.
Neoadjuvant and leucovorin. It starts from 5th
chemotherapy to Chemoradiation has postoperative day to the
downstage the tumour is become the standard end of 2 years
also used to make it adjuvant treatment.
operable later.
Palliative treatment
Options
Palliative partial gastrectomy is the best palliation
Palliative anterior gastrojejunostomy with jejuno-jejunostomy.
Palliative chemotherapy is used in advanced stage
Radiotherapy and analgesia like morphine is used to relieve pain.
Endoscopic stenting/dilatation
Location
MC site is duodenum followed by Pancreas
About 70-90% of gastrinomas are located within the Passaro’s triangle
Clinical Features
Abdominal pain
Diarrhea
GERD
Diagnosis
Hypergastrinemia with increased secretion of gastric acid
fasting serum gastrin level >100 pg/mL
Elevated serum gastrin level with a pH <2 in the gastric aspirate.
In Case of doust
Secretin Provocation Test: An increase of >200 pg/mL in the gastrin value after
administration of secretin is diagnostic
Treatment
Acid secretion is controlled by PPIs
Pharmacologic control of acid secretion with PPIs has rendered total
gastrectomy and other surgical acid-reducing procedures unnecessary
Distal pancreatectomy: Gastrinoma involving body or tail of pancreas
Pancreaticoduodenectomy: Gastrinoma involving headQof pancreas
Site
Almost always seen in the fundus& rarely in distal stomach.
Pathophysiology
Impaired mucosal defense mechanisms against luminal acid such as a reduction in
blood flow, mucus, and bicarbonate secretion by mucosal cells, or a reduction in
endogenous prostaglandins
Risk factors
ARDS
Multiple trauma
Major burn > 35% of BSAQ
Oliguric renal failure
Large transfusion requirements
Hypotension
Prolonged surgical procedures
Sepsis
Clinical Features
Painless upper GI bleeding
Diagnosis:
UGIE
Treatment
Definitive fluid resuscitation with correction of any coagulation abnormalities and
treatment of the underlying sepsis
Intraluminal gastric pH should be maintained >5.0 with antisecretory agents.
Most of the superficial erosions are not actively bleeding do not require ligature
unless a blood vessel is seen at its base.