GASTRIC CANCER

GASTRIC CANCER – Causes and Risk Factors, Pathophysiology, Signs and Symptoms, Stages, Diagnosis and Management

INTRODUCTION

Gastric cancer was once the second most common cancer in the world. In most developed countries, however, rates of stomach cancer have declined dramatically over the past half century. Men have higher incidence of gastric cancer than women. Most of these deaths occur in people older than 40 years of age.

Gastric cancer: tumors in the stomach can be benign or malignant. Gastric cancer is a disease in which tumors are found in the stomach. Stomach cancer is common throughout the world and affects all races, it is more common in men than women, and has its peak age range between 40 and 60 years old. If it is not diagnosed quickly, it may spread to other parts of your stomach as well as to other organs. There are twice as many males with this disease than females.

Stomach cancer usually begins in cells in the inner layer of the stomach. Overtime, the cancer may invade more deeply into the stomach wall. A stomach tumor can grow through the stomach’s outer layer into nearby organs, such as the liver, pancreas, esophagus, or intestine.

Causes/Risk Factors of gastric Cancer

• Helicobacter pylori infection: H.pylori is a bacterium that commonly infects the inner lining (the mucosa) of the stomach. Infection with H.pylori can cause stomach inflammation and peptic ulcers.
• Long-term inflammation of the stomach: people who have conditions associated with long-term stomach inflammation (such as the blood disease pernicious anemia) are at increased risk of stomach cancer
• Smoking: smokers are more likely than nonsmokers to develop stomach cancer. Heavy smokers are most at risk
• Family history: close relatives (parents, brothers, sisters, or children) of a person with a history of stomach cancer are somewhat more likely to develop the disease themselves. If many close relatives have a history of stomach cancer, the risk is even greater
• Poor diet, lack of physical activity
• Obesity people who eat a diet high in foods that are smoked, salted, or pickled have an increased risk for stomach cancer
• A lack of physical activity may increase the risk of stomach cancer

PATHOPHYSIOLOGY

Most gastric cancer is adenocarcinomas and occurs in portion of stomach —- the tumors infiltrate the surrounding mucosa —- penetrating the wall of the stomach and adjacent organs and structures —- the liver, pancreas esophagus and duodenum are often affected —- metastasis through lymph to the peritoneal cavity occurs later in disease

SIGNS AND SYMPTOMS

Stomach cancer is often asymptomatic or it may cause only nonspecific symptoms. By the time symptoms occur, the cancer has often reached an advanced stage and may have also metastasized. Stomach cancer can cause the following signs and symptoms.

STAGE 1 (Early)

• Indigestion or a burning sensation (heartburn)
• Loss of appetite, especially for meat
• Abdominal discomfort or irritation

Stage 2 (Middle)

• Weakness and fatigue
• Bloating of the stomach, usually after meals

Stage 3 (Late)

• Abdominal pain in the upper abdomen
• Nausea and occasional vomiting
• Diarrhea and constipation
• Weight loss
• Bleeding (vomiting blood or having blood in the stool) which will appear as black. This can lead to anemia.
• Dysphagia this feature suggests a tumor in the cardiac or extension of the gastric tumor into the esophagus

DIAGNOSIS

• Physical examination: abdomen for fluid, swelling, or other changes. Also will check for swollen lymph nodes
• Endoscopy: uses a thin, lighted tube (endoscope) to look into your stomach
• Biopsy: an endoscope has a tool for removing tissue
• Computed tomography or CT scanning of the abdomen may reveal gastric cancer, but is more useful to determine invasion into adjacent tissues, or the presence of spread to local lymph nodes
• Gastroscopic examination: this involves insertion of a fiber optic camera into the stomach to visualize it

MANAGEMENT

Treatment for stomach cancer may include surgery, chemotherapy, and radiation therapy

Surgery: surgery is the most common treatment. The surgeon removes part or all of the stomach, as well as surrounding lymph nodes, with the basic goal of removing all cancer and a margin of normal tissue.

• Endoscopic mucosal resection (EMR) is a treatment for early gastric cancer (tumor only involves the mucosa. In this procedure, the tumor, together with the inner lining of stomach (mucosa), is removed from the wall of the stomach using an electrical wire loop through the endoscope. The advantage is that it is a much smaller operation than removing the stomach
• Endoscopic submucosal dissection (ESD) is a similar technique used to resect a large area of mucosa in one piece. If the pathologic examination of the resected specimen shows incomplete resection or deep invasion by tumor, the patient would need a formal stomach resection
• Surgery to remove stomach cancer the types of operation have to remove stomach cancer will depend on which part of the stomach the cancer is in. if cancer is near the area where stomach joins food pipe (esophagus) may need part of food pipe removed as well.
• Gastric bypass procedures (GBP) – in this stomach is divided into a small upper  pouch and a much larger lower ‘remnant’ pouch and then re-arranges the small intestine to connect to both
• Radiation therapy is the use of high-energy rays to damage cancer cells and stop them from growing. When used, it is generally in combination with surgery and chemotherapy, or used only with chemotherapy in cases where the individual is unable to undergo surgery

COMPLICATIONS OF ABDOMINAL SURGERY

• Infection: infection of the incisions or of the inside of the abdomen (peritonitis, abscess) may occur due to release of bacteria from the bowel during the operation
• Venous thromboembolism: any injury, such as a surgical operation, causes the body to increase the coagulation of the blood
• Hemorrhage: many blood vessels must be cut in order to divide the stomach and to move the bowel. Any of these may later begin bleeding, either into the abdomen (intra-abdominal hemorrhage), or into the bowel itself (gastrointestinal hemorrhage)
• Hernia: a hernia is an abnormal opening, either within the abdomen or through the abdominal wall muscles. An internal hernia may result from surgery and re-arrangement abdominal of the bowel, and is a cause of bowel obstruction
• Bowel obstruction: abdominal surgery always results in some scarring of the bowel, called adhesions. A hernia, either internal or through the abdominal wall, may also result

Preoperative Management

• Preoperative assessment: the patient’s preoperative physiological status is a major factor in determining outcome after major surgery. Although scoring systems including a variety of parameters have been evaluated, the previous medical history and concurrent morbidity remain the strongest predictors
• Past medical history: a detailed medical history and physical examination is a prerequisite to the assessment of any anesthetic and operative risk. Cardiorespiratory disease has been identified as the commonest coexisting disease in patient presenting for esophagectomy. Pre-existing ischemic heart disease, poorly controlled hypertension, and pulmonary dysfunction are all associated with increased operative morbidity, particularly in the elderly and following upper abdominal and thoracic surgery. The efficacy of any medication prescribed for cardiorespiratory conditions should be evaluated at an early stage
• Social habits: smoking is a significant etiological factor in preoperative morbidity. All patients must be encouraged to stop smoking preoperatively
• Preoperative investigations: the minimum preoperative investigations for all patients undergoing gastric or esophageal surgery should include baseline hematological and biochemical profiles, arterial blood gases on air, pulmonary functions tests, a resting electrocardiogram, and a chest X-ray
• Nutritional status: obesity is associated with increased operative risk

Psychological Preparation

All patients should be counseled about treatment options, paying particular attention to the results and limitations of surgery. A clear description of the preoperative period should be given. An assessment of pretreatment symptoms on quality of life of the patient should be carefully undertaken as there is accumulating evidence of quality of life scores having an independent effect on outcome

Thromboembolic Prophylaxis

Appropriate measures should be taken against the risk of thromboembolic complications. Antithromboembolic stockings, low molecular weight heparin, and preoperative calf compression should be employed

• Antibiotic prophylaxis: broad spectrum antibiotic prophylaxis  should be administered preoperatively
• Blood cross match: four units of blood should be cross matched prior to surgery. Transfusion however should be avoided if at all possible as the immunological suppressive effect can adversely affect survival

Postoperative Management

• Meticulous attention to the maintenance of fluid balance and respiratory care are essential in the immediate postoperative period
• Pain control
• Pulmonary physiotherapy
• Early mobilization is important in the prevention of venous thrombosis and pulmonary embolism
• Promote pulmonary ventilation
• Provide adequate analgesic during few days
• Encourage ambulation
• Promote nutrition and family education
• Add food in small amount at frequent interval until well tolerated
• Monitor weight regularly

STOMACH CANCER (GASTRIC) PREVENTION

Gastric cancer can sometimes be associated with known risk factors for the disease. Many risk factors are modifiable though not all can be avoided

• Diet and lifestyle: excessive salt intake has been identified as a possible risk factor for gastric cancer. Having a high intake of fresh fruits and vegetables may be associated with a decreased risk of gastric cancer. Studies have suggested that eating foods that contain beta-carotene and vitamin C may decrease the risk of gastric cancer, especially if intake of micronutrients is inadequate
• Pre-existing conditions: infection with a certain bacteria, Helicobacter pylori, is associated with an increased risk of gastric cancer. Long standing reflux of gastric contents and the development of an abnormal cellular lining is also associated with an increased risk of cancer at the junction of the stomach and esophagus
• Cancer-fighting foods
• Citrus fruits: it is no secret that oranges, tangerines and clementines bring us vitamin C; they are among the richest sources of this critical vitamin

NURSING MANAGEMENT

Nursing assessment: careful selection of the varying therapeutic modalities is essential. Such selection should consider not only the nature of the symptoms to be relieved but also the general medical and psychological status of the patient. Decisions should be taken in the context of the predicted prognosis and the effect of any treatment intervention on quality of life

Nursing Diagnosis

Preoperative

• Acute pain related to the growth of cancer cells
• Anxiety related to plan surgery
• Imbalanced nutrition less than body requirements related to nausea, vomiting and no appetite
• Activity intolerance related to physical weakness

Postoperative

• Ineffective breathing pattern related to the influence of anesthesia
• Acute pain related to interruption of the body secondary to invasive procedures or surgical intervention
• Imbalanced nutrition less than body requirements related to fasting status
• Risk for infection related to an increased susceptibility secondary to the procedure

Intervention

• Encourage the patient to eat small and frequent portions of nonirritating foods to decrease gastric irritation
• Food supplements should be high in calories as well as vitamin A and C and iron to enhance tissue repair
• The nurse administers analgesic as prescribed
• A continuous infusion of an Opioid may be necessary for severe pain
• The nurse help the patient express fears, concern grief and diagnosis
• Encourage the patient to participate in treatment decisions