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Gastric Cancer (malignant tumour of stomach) (Diagnostic studies (staging…
Gastric Cancer (malignant tumour of stomach)
Risk factors
Helicobacter pylori -> increase risk of CA stomach
chronic atrophic gastritis with intestinal metaplasia
Related factors
more common on males & blacks
incidence increase with age
Clinical manifestations
Early
similar to gastric ulcer
progressively loss of appetite
early satiety (飽滿)
Dyspepsia 消化不良 for > 4 wks
occult blood in stools
vomiting
*Coffee-ground vomits -> is due to slow leaks of blood from ulceration of cancer
Later
weight loss
anaemia
haemorrhage
Pain: triggering factor: usually by eating; relieved factor: vomiting
Focused history taking
weight loss & fatigue over several months?
GI symptoms: anorexia, gastric fullness
diet & nutrition: eating pattern, type of food
any previous GI bleed?
medications? aspirin, NSAIDs, steroids
stressful lifestyle?
Abdominal assessment -> positive abdominal findings
Vital signs: BP/P lying & standing -> determine the presence of orthostatic/ postural hypotension due to bleeding
pain assessment:
location? characteristics? radiation of pain, intensity & duration, time of onset, triggering, aggravating & relieving factor
Visceral pain:
caused by stretching/ inflammation of a hollow muscular organ
Somatic pain
arises from the parietal peritoneum
focal pain, localised, sharp & severe
Diagnostic studies
lab studies
monitor CBC -> anaemia?
stool -> occult blood?
Upper GI radiography & endoscopy
for suspected gastric cancer
direct visualization of leasion
EUS+ Biopsy/ fine needle aspiration (FNA) if malignant cells not detected / for staging of carcinoma -> obtain tissue sample for histological & cytological review to differebtiate adenoma/ maglinant lymphoma
imaging studies (abdominal & pelvic CT scan) -> for detecting metastases
while bone/ liver scan -> determine extent of disease & metastasis
staging carcinoma of the stomach
laparotomy/ laparoscopy (the gold standard for assessing degree of local & distant invasion)
endoscopic ultrasonography ->measuring tumour depth
CT scanning -> assessing the involvement of adjacent structures and metastases
Managemant
Curative surgery (gastric resection)
total gastrectomy (oesophagojejunostomy) -> total removal of the stomach with anastomosis of oesophagues to jejunum
Partical gastrectomy
gastroduodenostomy (Billroth I) -> remove distal antrum & pylorus, duodenum is anastomosed to the gastric stump; dumping syndrome reduced
gastrojejunostomy (Billroth II) -> remove antrum and pylorus, jejunum is anastomosed to the gastric stump; pancreatic & bile secretions preserved
post- gastrectomy complications
hemorrhage
infection
dumping syndrome (uncommon in Billroth II gastrojejunostomy)
= excessively rapid (10-20min) emptying of gastric content into intestine due to loss of gastric capacity/ emptying control; high osmotic gradient within the small intestine causing sudden shift/ fluid from intravascular volume
s/s include: gastric fullness, nausea & vomiting, cramping, weakness, tachycardia, diarrhoea
encourage small & frequent meals, high in protein & fat, low carbohydrates diet, avoid meals high in milk, chocolate, salt, take fluid between meals but not with meals
alkaline flux gastritis (5-20%)
gastric irritation & inflammation due to reflux of bile & alkaline pancreatic secretion -> proteolytic enzyme disrupt the mucosal barriers
avoid alcohol, fatty diet & aspirin
anaemia (iron/ vit. b12/ folate deficiency)
replacing Vit. b12 by injection, iron & folate -> oral supplement
(Rare) Afferent Loop Obstruction = recurrent tumour growth, adhesion/ volvulus/ hernia at proximal duodenal stump (indication: low fat diet, surgery)
Palliation 緩和 for unresectable & metastatic tumour
Palliative surgery
endoscopic musocal resection
subtotal gastrectomy (with/ without gastroenterostomy) -> to maintain continuity of GI tract
surgery combined with chemotherapy
Radiotherapy
generally resistant to external beam radiation
combination chemoradiation post-op
Nursing diagnoses -> nursing intervention
imbalanced nutrition
administer parenteral nutrition
diet progression -> sips of water -> fluid (when audible bowel signs is present) -> increase fluid amount -> diet with vitamin supplement
promote comfort & wound healing
NG drainage to BSB + Q1H aspiration / suction -> to decompress stomach & prevent painful distension by gas/ fluid
dressing with aseptic technique
prevent infection & administer antibiotics & analgestics
prevent cardiopulmonary complications
assist turning
deep breathing & coughing exercise; use of respirometer
use of electric stocking -> prevent venous stasis if indicated
early ambulation to avoid deep vein thrombosis
monitor BP/P, resp.
note any S/S of SHOCK -> Pallor, Clammy skin, dizziness, change in level of consciousness
check dressing & suction canister frequently for bleeding
administer IV infusion & blood replacement as prescribed
patient edu. & health maintenance
review nutritional requirement with the patients
check fro tight dressings/ binder that might restrict circulation
instruct on measure to prevent dumping syndrome