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gastric cancer: malignant tumour of stomach (post-gastrectomy…
gastric cancer:
malignant tumour of stomach
risk factor
H. pylori increase incidence if CA stomach
chronic atrophic gastritis with intestinal metaplasia 胃裏出現小腸上皮的細胞
pernicious anaemia 惡性貧血
gastric surgery (>15yrs)
adenomatous polyps 腺瘤息肉
related factor
more common in men & blacks
incidence increase with age
clinical manifestation
early manifestations
similar s/s as gastric ulcer
progressive loss of appetite
early satiety 飽腹感
dyspepsia >4weeks
occult blood in stool
vomiting
may indicate pyloric obstruction/ cardiac-orifice obstruction
coffee-ground vomitus due to slow leaks of blood from ulceration of cancer
later manifestation
pain
trigger by eating
relieved by vomiting
weight loss
loss of strength
anaemia
metastasis (usually to liver)
menorrhage
obstruction of cardiac/ pyloric sphincter
abdominal/ epigastric pain
nursing assessment
focused history
weigh loss & fatigue over several months
GI symptoms
anorexia
early satiety
dyspepsia
vomiting
diet & nutrition
eating patterns & regularity
types of food
eating circumstances
premorbid status
previous GI bleed
medication
aspirin
NSAIDs
steroids
bowel history
psychosocial history: stressful life event
physical examination & abdominal assessment
＋ve abdominal findings
vital signs
Bp/P lying & standing check any orthostatic/ postural hypotension due to bleeding
pain assessment: location, characteristics, radiation of pain, intensity & duration, time of onset, triggering, aggravating & relieving factors
visceral pain: stretching/ inflammation of hollow muscular organ
somatic pain
arise from parietal peritoneum
focal pain, localized, sharp, severe
diagnostic studies
lab test
monitor CBC assess anaemia
check stool occult blood
upper GI radiography & endoscopy
suspected gastric cancer
direct visualization of lesion
EUS + biopsy/ fine needle aspiration (FNA) if malignant cells not detected/ for staging of carcinoma
obtain tissue samples for histological & cytological review to differentiate adenoma 腺瘤/ malignant lymphoma 淋巴瘤
imaging studies
abdominal & pelvic CT scan to detect metastases 轉移
bone/ liver scan to determine extend of disease & metastasis
management
curative surgery: gastric resection
total gastrectomy (oesophagojejunostomy)
total removal of stomach with anastomosis of oesophagus to jejunum
partial gastrectomy
gastroduodenostomy (billroth I)
removal of distal antrum & pylorus
duodenum anastomose to gastric stump
dumping syndrome reduced
gastrojejunostomy (Billroth II)
removal of antrum and pylorus
jejunum anastomose to gastric stump
pancreatic & bile secretion preserved
palliation
for unresectable & metastatic tumour
palliative surgery
endoscopic mucosal 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 postoperatively
post-gastrectomy complications
risk of hemorrhage
risk of infection
dumping syndrome
excessively rapid (10-20mins) emptying of gastric content into intestine due to loss of gastric capacity & emptying control
high osmotic gradient within small intestine --> sudden shift if fluid from intravascular volume
uncommon in Billroth II
clinical manifestation
cramping痙攣
gastric fullness
N/V
diarrhea
weakness
palpitation
perspiration 汗
tachycardia
hypotension
syncope 昏厥
intervention
small & frequent meal
high in protein & fat & low carbohydrate diet
avoid high in sugar. milk, chocolate, salt
take fluid between meals not with meals
take anticholinergic medication before meal to decrease GI activity
eat slowly & regularly in relaxing ambience環境
rest after meal
alkaline reflux gastritis
(5-20%)
gastric irritation & inflammation due to reflux of bile & alkaline pancreatic secretion
proteolytic 蛋白水解enzyme disrupt the mucosal barrier
intervention: avoid alcohol, fatty diet & aspirin
metastasis
death
anaemia
iron/ vit B12/ folate deficiency
intervention
replace B12 by injection
iron & folate supplement
afferent loop obstruction (rare)
recurrent tumour growth
adhesion/ volvulus/ hernia at proximal duodenal stump
intervention: low fat diet, surgery
nursing diagnosis
pain --> disease process/ surgery
risk of injury,
shock
& other complications --> surgery &
impaired gastric tissue function
imbalanced nutrition
: less than body requirements--> malignancy & treatment
fear --> uncertainty of disease & life-threatening changes (recurrence)
nursing intervention
promote comfort and wound healing
NG drainage to BSB + Q1H aspiration/ to suction as ordered--> decompress stomach & prevent painful distension by gas/ fluid
dressing with aseptic technique & note s/s of infection
prevent infection & administer antibiotics
administer analgesics as prescribed
prevent cardiopulmonary complications
assist turning to promote comfort & move, mobilizing pulmonary secretion
deep breathing & coughing exercise & use of respirometer to prevent pulmonary complications
use of elastic stocking to prevent venous stasis if indicated
early ambulation to avoid deep vein thrombosis & improve lung expansion
monitor BP/P & resp
note s/s of shock: pallor, clammy skin, dizziness, change in LOC
check dressing & suction canister罐 frequently check any bleeding
administer IVF & blood replacement as prescribed
attain adequate nutritional status
administer parental nutrition if ordered
follow prescribed diet progression
sip of water --> fluid when bowel signs heard
increase fluid as tolerated
offer a diet with vitamin supplement when pt's condition permits
pt education and health maintenance
explore effective coping with stressful situations
review nutritional requirement with pt
check for tight dressings/ binder that might restrict circulation
instruct measures to prevent dumping syndrome
stress the importance of IM vit B12 supplements after gastrectomy to prevent surgically induced pernicious anaemia 惡性貧血
provide info of support group
encourage follow-up for annual blood & medical checkup