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JC WCS > Upper GI Surgery JC058: Weight Loss And Vomiting: Gastric Cancer, Abdominal Imaging > Flashcards

Upper GI Surgery JC058: Weight Loss And Vomiting: Gastric Cancer, Abdominal Imaging Flashcards

1
Q

***Mechanical GI obstruction

A

記: 4 Cardinal presentations Intestinal obstruction:
1. **Abdominal distension
2. **Abdominal pain
3. **Vomiting
4. **Constipation

High obstruction:
- **Frequent vomiting
- **No distension
- Intermittent pain but not classic crescendo type

Middle obstruction:
- Moderate vomiting
- Moderate distension
- Intermittent pain (crescendo, colicky) with free intervals

Low obstruction:
- **Late vomiting (Faeculent)
- **Marked distension
- Variable pain (may not be classic crescendo type)

Esophagus:
- Dysphagia
- Regurgitation (Not vomiting ∵ not much muscular action + contain little amount of content)

Stomach:
- Vomiting (∵ capable muscular action to produce sudden force to release content + can contain large amount of content)

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2
Q

Upper GI obstruction

A
  1. Nature of vomitus (differentiate Proximal vs Distal to D2)
    - ***Bile stained —> distal to D2
    - NOT Bile stained —> proximal to D2
  2. Bulge (distension) in epigastrium
  3. Succussion splash
    - ***gastric outlet obstruction

Vomiting, Weight loss, Gradual onset, Elderly:
- consider ***Gastric cancer with outlet obstruction

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3
Q

Epidemiology of Gastric adenocarcinoma

A
  • ↓ Incidence
  • 3rd leading cause of cancer deaths worldwide (6th in HK)
  • Incidence varies globally (High incidence in Asia)
  • Still very common (∵ aging population)
  • Disease of elderly
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4
Q

Risk factors of Gastric adenocarcinoma

A
  1. Diet
    Harmful dietary factors
    - **N-nitroso compounds (e.g. nitrates) (make meat pink)
    - **    Preserved, smoked, salted food

Protective dietary factors
- Trace elements
- Vit C
- ***Fresh fruits and vegetables

  1. ***Smoking
  2. ***Atrophic gastritis
  3. ***Pernicious anaemia
  4. Adenomatous polyps
  5. Menetrier’s disease
  6. ***Previous partial gastrectomy (>20 years)
  7. ***EBV (apart from NPC, Burkitt lymphoma)
  8. Industrial (dusty, high temperature, rubber, coal mining, metal processing, chromium production)
  9. Common variable immunodeficiency (CVID)
  10. Hereditary (E-cadherin mutation)
  11. ***H. pylori (WHO group 1 carcinogen) (2-3% chance)
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5
Q

Linitis plastica

A

A type of Gastric cancer:
- “Leather bottle” stomach
- Cancer invade + spread via **Submucosal layer —> Mucosa can appear “normal” on endoscopy —> easily missed
- **Thickened gastric wall (>5mm)
- Rigid, cannot be distended with air

Features:
- **Smaller stomach
- **Cannot distend lumen with air insufflation

Solution:
- Take deeper bite on biopsy on suspicion

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6
Q

Mode of spread of Gastric adenocarcinoma

A
  1. Direct invasion
    - anterior: Liver
    - lateral: Spleen
    - inferior: Colon
    - posterior: Pancreas
  2. Lymphatic
    - richly supplied by lymphatic network
  3. **Transcoelomic / **Transperitoneal
    - seedlings of peritoneum (small, easily missed by CT)
    - associated **Ascites
    - **    Krukenberg tumour: Ovarian metastasis
  4. Haematogenous
    - Liver, Lung
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7
Q

***Clinical presentation of Gastric adenocarcinoma

A

Notoriously difficult to make an early diagnosis
1. Asymptomatic
2. Distending discomfort, **Vomiting (Splash) (if Obstruction)
3. **Anaemia, Pallor, Melena, Haematemesis (if Bleeding)
4. Perforation with acute peritonitis (Rare)
5. **Epigastric pain
6. Anorexia, Weight loss (late presentation), Malaise, Weakness
7. Dysphagia (if Cardia involved)
8. **Abdominal mass (Primary, Omental, Krukenberg)
9. **Acanthosis nigricans (Dark discolouration of body folds, also present in DM)
10. Paraneoplastic syndrome (e.g. Nephrotic syndrome)
11. **Metastatic disease
- **Ascites
- **Jaundice (biliary obstruction by LN metastasis, liver metastasis)
- **Left supraclavicular LN (Virchow’s node, Troisier’s sign), Left axillary node (Irish’s)
- **Dyspnea (pleural effusion, lymphangitis carcinomatosis: diffuse lung metastasis through LN in lung parenchyma)
- **Hepatomegaly
- **Sister Mary Joseph node (indicate peritoneal spread, also present in intraabdominal malignancy with peritoneal spread)
- Acute renal failure / hydronephrosis (obstruction of ureter)
- Rectal (Blumer’s) shelf (rectum feel like hard tube)

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8
Q

Investigations

A
  1. CBP, LRFT
  2. ***Upper endoscopy + Biopsy (diagnostic)
  3. CXR
  4. **CEA, **CA19.9 (for monitoring after treatment, follow up)
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9
Q

2 main questions after diagnosis

A
  1. Stage of disease
    - TNM
    —> AJCC
    —> UICC
    —> JGCA
    - T: Depth of invasion
    - N: No. of LN with metastasis
    - M: Presence / Absence of systemic metastasis
  2. Whether patient is fit for surgery / treatment?
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10
Q

Clinical staging

A
  1. History, P/E
  2. LFT
  3. CXR
  4. USG / CAT scan (i.e. CT abdomen)
  5. ***PET / CT
  6. ***Endoscopic USG
    - for regional local staging (gastric wall / LN involvement)
  7. ***Laparoscopy
    - for peritoneal spread
    - done immediately before surgery
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11
Q

Treatment of Gastric adenocarcinoma

A
  • Depends on fitness + clinical stage
  • Resection: only hope for cure for resectable disease
  • In HK, 70% present with diseases ***>= Stage 3

Early cancer (T1, mucosal)
- rare in HK
- Japan: Screening endoscopy
- **EMR (Endoscopic Mucosal Resection): not useful for larger lesions
- **ESD (Endoscopic Submucosal Dissection) (片皮鴨)
- ***Laparoscopic gastrectomy
—> Laparoscopic assisted vs Total Laparoscopic
—> Hand sewn vs Stapled
—> Billroth 1 vs 2

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12
Q

Resectable gastric cancer

A
  1. Gastric resection with ***D2 LN dissection
  2. ***Distal resection (for distal lesion)
  3. ***Proximal resection (for GEJ lesion)
  4. **Total gastrectomy (for proximal / body lesion)
    - **    Roux-en-Y reconstruction —> prevent bile reflux
    - ***Esophagojejunostomy
  5. Adjuvant chemotherapy (for ***advanced cancer: Stage 2/3)
  6. Neoadjuvant chemotherapy (for selected patients: ***Downstaging first)

Others:
7. Targeted therapy (e.g. gastric cancer with **HER2 mutation —> **Trastuzumab)
8. Immunotherapy

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13
Q

Unresectable disease

A
  1. Supportive care, Pain control
  2. ***Palliative resection for bleeding
  3. Palliative bypass (Gastrojejunostomy) for outlet obstruction
    - higher morbidity
    - provide better QOL
  4. ***Systemic chemotherapy (for younger patients)
  5. ***Endoscopic stenting
    - less morbidity
    - limited diameter
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14
Q

Chemotherapy

A
  1. Primary
  2. Adjuvant
  3. Neoadjuvant
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15
Q

Value of diagnostic imaging

A
  1. Staging
    - CXR
    - CT
    - PET
  2. Diagnosis
    - **Intestinal obstruction
    - **    Malignant biliary obstruction
    - ***Malignant ureteric obstruction
  3. Monitoring response to treatment
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JC WCS (134 decks)

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