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
- Malignancy seen increasingly with age - most are adenocarcinoma
- 6th commonest cause of cancer in UK with a 10% 5-year survival
- Twice as common in males
Histology
- Adenocarcinoma: The most common type, accounting for about 90-95% of gastric cancers, originates from the glandular cells of the stomach lining.
- Lymphomas: Cancers that originate in the immune cells within the stomach wall.
- Gastrointestinal Stromal Tumours (GISTs): Rare tumours that develop from the interstitial cells of Cajal in the stomach wall.
- Neuroendocrine Tumours: Arise from the hormone-producing cells of the stomach.
Pathology
- Tumours can be infiltrating, a malignant ulcer or malignant polypoid tumour
- Diffuse infiltrating tumour spread rapidly into submucosa - linitis plastica
- Local spread to liver, pancreas, transverse colon, stomach wall, peritoneum
- Lymph spread is to nodes along lesser and greater curves of the stomach and then to supraclavicular
- Spread via the bloodstream to liver and lungs
- Transcoelomic spread to ovaries - Krukenberg tumour
Epidemiology
- Commonest in Japan and Chile
- Cancer of cardia and GOJ increasing and antrum falling
Risks
- Helicobacter pylori Infection: Chronic infection with H. pylori bacteria is a major risk factor for gastric cancer.
- Diet: High intake of salty and smoked foods, low consumption of fruits and vegetables
- Smoking: Tobacco use increases risk of gastric cancer.
- Family History: history of gastric cancer, especially hereditary diffuse gastric cancer (HDGC), increases risk.
- Chronic Gastritis: Inflammation of the stomach lining, often due to H. pylori
- Pernicious Anaemia: Affects the stomach lining and vitamin B12 absorption, increasing cancer risk.
- Age and Gender: More common in older adults and more frequently affects males.
Clinical
- Dyspepsia, Early satiety, epigastric discomfort
- Anorexia, Weight loss, nausea, vomiting
- Severe vomiting due to gastric outlet obstruction
- Haematemesis, Melaena, Dysphagia
- Liver spread causes jaundice and pain and ascites
- Epigastric mass
- Lymph nodes left supraclavicular fossa (Virchow's node/ Troisier's sign)
- Metastatic nodule at Umbilicus - Sister Mary Joseph nodule
Investigations
- Endoscopy: enables visualisation and biopsies.
- Biopsy: biopsy during endoscopy to be examined for cancer cells.
- Imaging: CT scans, PET scans, and endoscopic ultrasound (EUS) help.
- Blood Tests: FBC, U&E, CEA and CA 19-9.
Complications
- Fe def Anaemia, Gastric outlet obstruction
- B12 deficiency following gastrectomy
- Dumping syndromes at follow gastrectomy
- Dysphagia
- Acute upper GI haemorrhage
Management
- Total gastrectomy and removal or drainage lymph nodes for proximal lesions with a Roux-en-Y loop reconstruction anastomosing small bowel to distal oesophagus
- Subtotal gastrectomy if distal pylorus or antral lesions. Adjacent involved tissues may also be resected e.g. tail of pancreas, spleen, colon, omentum, duodenum etc
- Advanced cases then treated on a case by case assessment of benefits of surgery,
- Adjunctive chaemotherapy can reduce recurrence and improve survival in advanced disease. Commonly used agents include 5-Fluorouracil, epirubicin, platinum agents and capecitabine. Role of radiotherapy unclear.
- Advanced cancer with Pyloric obstruction - palliative gastroenterostomy or stenting may be possible.
- Overall prognosis is poor with 20% 5-year survival
- Mucosal Gastric lymphomas may be treated with local eradication of Helicobacter pylori and if no response then radio/chaemo/surgery
Prognosis
- Early Detection: When detected early, gastric cancer can often be cured with surgery. However, early detection is challenging because symptoms are often mild or absent.
- Advanced Disease: Prognosis is generally poor for advanced gastric cancer, especially if it has spread (metastasized) to other organs.