Makindo Medical Notes

Related Subjects: |Upper Gastrointestinal Bleed |Oesophageal Variceal Bleeding |Dieulafoy Lesion |Mallory-Weiss Tear |Gastric Cancer |Peptic Ulcer Disease |Oesophagogastroduodenoscopy (OGD/EGD) |Hereditary Haemorrhagic Telangiectasia |Hypovolaemic or Haemorrhagic Shock

Increasing incidence in proximal gastric tumour around the OGJ

About

• Gastric malignancy incidence rises with age; most cases are adenocarcinomas.
• 6th most common cause of cancer in the UK, with a 10% five-year survival rate.
• Twice as common in males compared to females.

Histology

• Adenocarcinoma: Most common type, accounting for 90-95% of gastric cancers, originates from glandular cells in the stomach lining.
• Lymphomas: Cancers originating in immune cells within the stomach wall.
• Gastrointestinal Stromal Tumours (GISTs): Rare tumours from interstitial cells of Cajal in the stomach wall.
• Neuroendocrine Tumours: Arising from hormone-producing cells in the stomach.

Pathology

• Tumours may present as infiltrating, malignant ulcers, or polypoid tumours.
• Linitis plastica: Diffuse infiltrating tumour that rapidly spreads into submucosa.
• Local spread to liver, pancreas, transverse colon, peritoneum, and stomach wall.
• Lymph spread to nodes along stomach curves, supraclavicular nodes.
• Bloodstream spread to liver and lungs; transcoelomic spread to ovaries (Krukenberg tumour).

Epidemiology

• Highest incidence in Japan and Chile.
• Increasing rates of cancer in the cardia and gastroesophageal junction, while rates in the antrum are decreasing.

Risk Factors

• Helicobacter pylori Infection: Major risk factor linked to chronic inflammation.
• Diet: High intake of salty, smoked foods; low fruit and vegetable intake.
• Smoking: Tobacco use increases gastric cancer risk.
• Family History: Especially hereditary diffuse gastric cancer (HDGC).
• Chronic Gastritis: Persistent inflammation of the stomach lining.
• Pernicious Anaemia: Impairs vitamin B12 absorption, increasing cancer risk.
• Age and Gender: More common in older adults, particularly males.

Clinical Features

• Dyspepsia, early satiety, and epigastric discomfort.
• Anorexia, weight loss, nausea, and vomiting.
• Severe vomiting due to gastric outlet obstruction.
• Haematemesis, melaena, dysphagia in advanced cases.
• Signs of liver spread: jaundice, pain, ascites.
• Physical signs: Epigastric mass, Virchow's node (left supraclavicular node), Sister Mary Joseph nodule (umbilical metastasis).

Investigations

• Endoscopy: Direct visualization and biopsy.
• Biopsy: Essential to confirm malignancy during endoscopy.
• Imaging: CT, PET scans, and endoscopic ultrasound (EUS) for staging.
• Blood Tests: Full blood count (FBC), U&E, tumour markers (CEA, CA 19-9).

Complications

• Iron deficiency anaemia, gastric outlet obstruction.
• B12 deficiency and dumping syndrome post-gastrectomy.
• Dysphagia, acute upper GI haemorrhage.

Management

• Total Gastrectomy: For proximal lesions, often with Roux-en-Y reconstruction.
• Subtotal Gastrectomy: For distal lesions, with possible resection of adjacent organs if involved.
• Advanced Disease: Case-by-case assessment for benefits of surgery.
• Adjunctive Chemotherapy: Agents like 5-Fluorouracil, epirubicin, platinum agents, capecitabine to reduce recurrence and improve survival.
• Palliative Options: Pyloric stenting or gastroenterostomy for pyloric obstruction.
• Gastric Lymphomas: Often treated with H. pylori eradication; other cases may require chemo/radio/surgery.

Prognosis

• Early Detection: Curative surgery possible with early detection, though challenging due to mild symptoms.
• Advanced Disease: Prognosis poor for metastasized cases; overall five-year survival around 20%.