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4. Gastric Cancer

  1. Presented by: Ms. Elizabeth M.Sc (N) Asst. Professor, Dept of MSN, NNC, GNSU
  2. Anatomy The stomach has 5 parts • Cardia: The first portion (closest to the esophagus) • Fundus: The upper part of the stomach next to the cardia. • Body (corpus): The main part of the stomach, between the upper and lower parts. • Antrum: The lower portion (near the intestine), where the food is mixed with gastric juice. • Pylorus : The last part of the stomach, which acts as a valve to control emptying of the stomach contents into the small intestine.
  3. • The first 3 parts of the stomach (cardia, fundus, and body) are sometimes called the • Some cells in these parts of the stomach make acid and pepsin (a digestive enzyme), the parts of the gastric juice that help digest food. • They also make a protein called intrinsic factor, which the body needs to absorb vitamin B12. • The lower 2 parts (antrum and pylorus) are called the • The stomach has 2 curves, which form its inner and outer borders. They are called the , respectively.
  4. Blood supply Most of the blood supply to the stomach is from Four main arteries • Left gasrtic artery • Right gastric artery • Right gastroepiploic artery
  5. Venous drainage • Left and right gastric vein • Right gastroepiploic vein • Left gastroepiploic vein
  6. Lymphatic drainage It has into four zones: • Superior gastric • Suprapyloric • Pancreaticolienal • Inferior gastric/subpyloric
  7. Stomach has five layers: • Mucosa • Sub mucosa • Smooth muscle layer • Sub serosa • Serosa
  8. Stomach cancer begins when cancer cells form in the inner lining of stomach. These cells can grow into a tumor. Also called gastric cancer, the disease usually grows slowly over many years.
  9. Predisposing factor • Pernicious anaemia • Atrophic gastritis • Previous gastric resection • Chronic peptic ulcer • Smoking • Alcohol. Environmental Factor • H.pylori infection • Diet • Low socioeconomic Status • Nationality (JAPAN) Genetic Factor • .Blood group A • Hereditary non- polyposis colon cancer (HNPCC).
  10. Clinical Presentation Common clinical Presentation: 3A”s: 1.Anaemia(due to bleeding from tumour) 2.Asthenia(septic absorption from the tumour) 3.Anorexia • onset of early satiety, dyspepsia, epigastric discomfort
  11. Specific symptoms depending on the site of tumour. - gastric outlet obstruction. - dysphagia, hamaetemesis. - mass per abdomen(silent variety). - jaundice, ascites
  12. • Grossly Anemic, • Cachexia, • Epigastric mass, • Virchows node • Sister mary joseph node • Krukenberg tumor • Irish node
  13. Stages of gastric cancer
  14. Staging of Gastric Cancer T1 - lamina propria & sub - mucosa T2 - muscularis & sub - serosa T3 - serosa T4 - Adjacent organs N0 - no lymph node N1 - Epigastric node N2 - main arterial trunk Mo - distal metastasis M1 - distal metastasis
  15. Spread of Gastric Cancer • Direct Spread • Blood-borne metastasis • Lymphatic spread • Transperitoneal spread
  16. INVESTIGATIONS • Full blood count • LFT, RFT • Stool examination for occult blood • CXR • Serum tumor markers (CA 72-4,CEA,CA19- 9)
  17. • Diagnostic study of choice - USG, CT, biopsy • UGI endoscopy with biopsy, CT, MRI & USG Laparoscopy • Upper gastro intestinal endoscopy - Diagnostic accuracy is 98% if upto 7 biopsies is taken. • Laparoscopy: Help in assessment of wall thickness, metastases (peritoneum ,liver & LNs) Help in assessment of wall thickness, metastases (peritoneum ,liver & LNs) Detection of peritoneal metastases
  18. Management Surgery Chemotherapy Radiotherapy
  19. Initial treatment 1.Improve nutrition if needed by parentral or enteral feeding. 2.Correct fluid &electrolyte & anemia if they are present.
  20. Though some superficial cancers can be treated endoscopically, gastrectomy is the most widely used approach 1. Total gastrectomy - usually performed for lesions in the upper third (proximal) stomach 2. Distal subtotal gastrectomy - performed for tumors in the distal (lower two- thirds) of the stomach
  21. RADICAL GASTRECTOMY • Remove the stomach +distal part of esophagus+ proximal part of duodenum + greater & lesser omentum + Lymph Nodes • Oesophagojejunostomy with roux-en-y gastric bypass surgery
  22. SUBTOTAL GASTRECTOMY • Similar to total one except that the PROXIMAL PART of the stomach is preserved • Followed by reconstruction & creating anastomosis ( by gastrojejunostomy, billroth II )
  23. Billroth - II
  24. PALLIATIVE SURGERY • For pts with advanced (inoperable) disease & suffering significant symptoms e.g. obstruction, bleeding. • Palliative gastrectomy not necessarily to be radical, remove resectable masses & reconstruct (anastomosis/intubation/stenting/ recanalisation)
  25. POSTOPERATIVE ORDERS • Admit to PACU • Detailed nutritional advise (small frequent meals)
  26. Post-Operative Complications • Leakage from duodenal stump. • Secondary hemorrhage. • Nutritional deficiency in long term.
  27. Chemotherapy Responds well, but there is no effect on survival. - Epirubicin, cisplatin &5-flurouracil (3 wks) 6 cycles 40% .
  28. Radiotherapy may decrease the recurrence.
  29. Nursing Diagnosis • Acute Pain • Altered Nutrition: Less Than Body Requirements • Risk for Fluid Volume Deficit • Fatigue • Risk for Infection • Risk for Altered Oral Mucous Membranes • Risk for Impaired Skin Integrity
  30. • Anticipatory Grieving • Situational Low Self-Esteem • Risk for Altered Sexuality Patterns • Risk for Altered Family Process • Fear/Anxiety • Risk for Constipation/Diarrhea
  31. Nursing Management • Monitor nutritional intake and weigh patient regularly. • Monitor CBC and serum vitamin B12 levels to detect anemia, and monitor albumin and prealbumin levels to determine if protein supplementation is needed. • Provide comfort measures and administer analgesics as ordered. • Frequently turn the patient and encourage deep breathing to prevent pulmonary complications, to protect skin, and to promote comfort. • Maintain nasogastric suction to remove fluids and gas in the stomach and prevent painful distention.
  32. • Provide oral care to prevent dryness and ulceration. • Keep the patient nothing by mouth as directed to promote gastric wound healing. Administer parenteral nutrition, if ordered. • When nasogastric drainage has decreased and bowel sounds have returned, begin oral fluids and progress slowly. • Avoid giving the patient high-carbohydrate foods and fluids with meals, which may trigger dumping syndrome because of excessively rapid emptying of gastric contents. • Administer protein and vitamin supplements to foster wound repair and tissue building.
  33. • Eat small, frequent meals rather than three large meals. • Reduce fluids with meals, but take them between meals. • Stress the importance of long term vitamin B12 injections after gastrectomy to prevent surgically induced pernicious anemia. • Encourage follow-up visits with the health care provider and routine blood studies and other testing to detect complications or recurrence.