Gastric carcinoma

Question 1

What type of cancer form the vast majority of gastric carcinomas?

Answer 1

• Adenocarcinoma

- Sporadic

Question 2

What gastric pathology most facilitates the progression to gastric carcinoma?

Answer 2

Chronic atrophic gastritis

Question 3

Risk factors for gastric Ca?

Answer 3

Preserved foods (salted, dried)
Lack of fresh/refrigerated foods
Saltpetre (potassium nitrite, used for meat salting and preservation)
Eppstein Barr virus
Previous gastric surgery (Billroth II > I; due to reflux of alkaline bile and subsequent chronic gastritis)
Abdominal irradiation
Blood group A
Familial predisposition
Hereditary diffuse gastric cancer
Pernicious anaemia

Question 4

What is Correa’s hypothesis of gastric carcinoma?

Answer 4

Nutritional defects (absence of fresh food, preservatives, alcohol, smoking, H. pylori) damage mucosa --> gastritis --> chronic gastritis --> metaplasia --> dysplasia --> adenocarcinoma
Cell damage --> reduced HCl --> bacterial proliferation (produce nitrate reductase, produces carcinogenic nitrosamines)

Question 5

What are the two types of gastric adenocarcinomas according to Lauren’s classification?

Answer 5

Diffuse
Intestinal
(Mixed)

Question 6

What are the features of intestinal type gastric adenocarcinoma?

Answer 6

Macroscopic: Ulceration
Microscopic: Acinar formation
Gastric site: Antrum
Prognosis:

Question 7

What are the features of diffuse type gastric adenocarcinoma?

Answer 7

Macroscopic: Cosntricting; linitis plastica
Microscopic: No acini
Gastric site: Fundus
Prognosis: Worse

Question 8

Clinical presentation of gastric carcinoma?

Answer 8

• Dyspepsia: 60%
• Local complication : 30%
  + haemorrhage
  + obstruction
  + perforation
• Insidious: 10%
  + loss of weight
  + anaemia
  + metastases

Question 9

Differential diagnosis of dyspepsia?

Answer 9

Functional (non-ulcer dyspepsia)
Peptic ulcer disease
Gastritis
GORD
Oesophagitis
Drug side effects
Biliary disease
Gastric carcinoma
Other e.g. pancreatic carcinoma

Question 10

Causes of gastric outlet obstruction?

Answer 10

Gastric carcinoma
Peptic ulcer
Pancreatic pathology
Carcinoma or pseudocyst
Corrosive stricture
Rarities: bezoar, volvulus, adenopathy

Question 11

When does dyspepsia become significant? What should be done at this point?

Answer 11

After it has lasted >2 weeks

This requires thorough investigation before medical treatment, as this treatment may resolve symptoms of gastric cancer

Question 12

What is the primary investigation for suspected gastric cancer?

Answer 12

Endoscopy, with tissue biopsy if relevant

Question 13

Secondary investigations of gastric cancer?

Answer 13

• Biopsy and histological diagnosis
• Metastatic screen (CXR, liver profile, U/S, CT)
• Assess extent of cancer (barium meal/CT/staging laparoscopy/endoscopic U/S)
• Assess fitness for surgery

Question 14

When is surgery appropriate for gastric cancer?

Answer 14

70% of patients
If irresectable/obstructed: bypass stent
If resectable:
   - curative: T1-3, N0-1, M0
   - palliative

Question 15

When is surgery inappropriate for gastric cancer?

Answer 15

30% of patients
Disease factors: metastases, ascites, local invasion
Patient factors: elderly, compromised, refusal

Question 16

What is a Bilroth I procedure and when is it used?

Answer 16

Partial gastrectomy with anastomosis of stomach to the duodenum
Used less commonly to manage lesions of the distal half of the stomach

Question 17

What is a Bilroth II procedure and when is it used?

Answer 17

Partial gastrectomy with anastomosis of stomach to proximal loop of jejenum (end-to-side gastrojejenuostomy)
Used commonly to manage lesions of the distal half of the stomach

Question 18

What is a Roux-en-Y procedure and when is it used?

Answer 18

Gastrojejenustomy where jejunum is attached to upper half of stomach side-on
Used less commonly to manage lesions of the distal half of the stomach

Question 19

Which procedure is used to manage gastric cancer of the proximal portion/extensive local disease?

Answer 19

Total gastrectomy and oesophagojejunal anastomosis