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 tumours 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 in over 95%
- Lymphoma
- Leiomyosarcoma and carcinoid are rare
Pathology
- Tumours can be infiltrating, a malignant ulcer or malignant polypoid tumour
- Diffuse infiltrating tumours 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
- Atrophic gastritis, Blood group A
- Pernicious anaemia x5, Adenomatous polyps
- Smoked processed spicy and salty foods
- Smoking, Alcohol
- Helicobacter pylori, Menetrier's disease
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
- Screening is done in Japan where there is a high incidence
- Upper GI endoscopy - biopsy lesions
- FBC - ? Hb ? MCV ? Ferritin - iron deficient anaemia
- CXR
- LFT/USS - ? ALP metastatic disease
- CT/MRI staging
- Laparoscopy to assess operability - peritoneal spread cannot be seen on imaging
Complications
- Fe def Anaemia, Gastric outlet obstruction
- B12 deficiency following gastrectomy
- Dumping syndromes th 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 chemotherapy 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/chemo/surgery