ETIOLOGY:

Diet:

 High in smoked, salted, or pickled foods

 Low in fruits and vegetables

Chronic inflammation of the stomach:

 H. Pylori infection
- H. Pylori is a gram- negative bacterium that causes chronic inflammation in the stomach and
duodenum and is a common contagious cause of ulcers worldwide.
-Invades the lining of the stomach producing a cytotoxin and can lead to ulcer formation.
 Pernicious anemia
- People who have had stomach surgery, pernicious anemia, or achlorhydria have a higher
risk of stomach cancer. Pernicious anemia is a severe decrease in red blood cells caused
when the stomach is not able to properly absorb vitamin B12.
- Certain cells in the stomach lining normally make a substance called intrinsic
factor (IF) that we need to absorb vitamin B12 from foods. People without enough IF may
end up with a vitamin B12 deficiency, which affects the body’s ability to make new red blood
cells and can cause other problems as well. This condition is called pernicious anemia. Along
with anemia (too few red blood cells), people with this disease have an increased risk of
stomach cancer.
 Smoking
 Achlorhydria (absence of hydrochloric acid in gastric secretions)
- Hydrochloric acid in the gastric juice breaks down the food and the digestive enzymes split
up the proteins.
- It also kills bacteria protecting your body from harmful microbes which can enter your body
in food.
 Gastric ulcers
- Gastric ulcers are open sores in the stomach that bacteria can easily infect.
- It causes mutations in the DNA and damages the cells of the stomach lining
- Prolonged inflammation can lead to chronic inflammation of the stomach and even stomach
cancer.

Assessment and Diagnostic findings:

 Physical examination is usually not helpful in detecting the cancer because most early gastric
tumors are not palpable.
 Ascites and hepatomegaly (enlarged liver) may be apparent if the cancer cells have
metastasized to the liver.
 Sister Mary Joseph’s nodules: Indicates malignancy
 Esophagogastroduodenoscopy: Test of choice for Gastric Cancer
- During this test, the doctor passes an endoscope, which is a thin, flexible, lighted tube with
a small video camera on the end, down your throat. This lets the doctor see the lining of
your esophagus, stomach, and first part of the small intestine.
 - Endoscopic ultrasound is an important tool to assess tumor depth and any lymph node
involvement
 Computed tomography (CT Scan): to assess for surgical resectability of the tumor before surgery
is scheduled.
 CT of the chest, abdomen and pelvis is valuable in staging gastric cancer.

Gerontologic Considerations:

Despite the decreased incidence of gastric cancer, the number of older patients (75 years of age and
older) with gastric cancer is increasing (Orsenigo, Tomajer, Di Palo, et al., 2007). Sixty percent of
cancer-related deaths occur in people 65 years of age and older (Jansen, Weert, Dulmen, et al., 2007).
Confusion, agitation, and restlessness may be the only symptoms seen in elderly patients, who may
have no gastric symptoms until their tumors are well advanced. At this time, they present with
reduced functional ability and other signs and symptoms of malignancy. Surgery is more hazardous
for the elderly, and the risk increases with age. Gastric cancer should be treated with traditional
surgery in older patients; the survival rate does not differ significantly from that of younger patients
(Gasparini, Inelmen, Enzi, et al., 2006). Patient education is important to prepare older patients with
cancer for treatment, to help them manage adverse effects, and to face the challenges that cancer
and aging present.

Gastric Surgery:
 Performed on patients with peptic ulcers who have life threatening hemorrhage, obstruction,
perforation or penetration or whose condition does not respond to medication.
 Indicated for patients with gastric cancer or trauma.

Vagotomy:
Vagotomy is the surgical cutting of the vagus nerve to reduce acid secretion in the stomach.
Purpose: The vagus nerve trunk splits into branches that go to different parts of the stomach. Stimulation
from these branches causes the stomach to produce acid. Too much stomach acid leads to ulcers that may
eventually bleed and create an emergency.

The vagus nerve helps manage the complex processes in your digestive tract, including signaling the
muscles in your stomach to contract and push food into the small intestine. A damaged vagus nerve
can't send signals normally to your stomach muscles.
A vagotomy is performed when acid production in the stomach cannot be reduced by other means. The
purpose of the procedure is to disable the acid-producing capacity of the stomach. It is used when
 ulcers in the stomach and duodenum do not respond to medication and changes in diet. It is an
appropriate surgery when there are ulcer complications, such as obstruction of digestive flow,
bleeding, or perforation.

Pyloroplasty: a surgical procedure in which the pylorus valve at the lower portion of the stomach is cut
and resutured, relaxing and widening its muscular opening (pyloric sphincter) into the duodenum (first
part of the small intestine)

Pyloroplasty surgery enlarges the opening through which stomach contents are emptied into the
intestine, allowing the stomach to empty more quickly. A pyloroplasty is performed to treat the
complications of PUD or when medical treatment has not been able to control PUD in high-risk
patients.

The pylorus is a thick, muscular area. When it thickens, food cannot pass through.
Cause: Unknown, but genetic and environmental factors might play a role. 

Partial Gastrectomy:

 A partial gastrectomy is a surgical procedure that is performed to remove a portion of the

stomach to treat stomach cancer and benign stomach tumors.
 When a partial gastrectomy is used as a treatment for stomach cancer, it is performed by a
surgical oncologist (a surgeon who specializes in treating cancer)
During a partial gastrectomy, a surgical oncologist will remove the cancerous part of the stomach,
along with nearby lymph nodes (this can help a pathologist determine if the cancer has started to
spread). Typically, a portion of the stomach is removed. The surgeon may also remove other organs
during a partial gastrectomy if there are visible signs of cancer in the:

 Spleen
 Colon
 Pancreas
 Small intestine
If the lower portion of the stomach is removed during surgery, the upper portion will be connected
directly to the small intestine. M
Total Gastrectomy:

 Doctors remove the entire stomach, surrounding lymph nodes and fatty tissue. Next, the surgical
team connects the esophagus to the intestines.
 A surgeon may create a new “stomach,” or pouch, by folding over a portion of the intestines, to
allow for more effective digestion.

After stomach surgery, some patients may have what is commonly known as dumping syndrome.
Without a stomach to hold the intake of food and fluids, there is no way to regulate the amount of food
entering the intestine.  You no longer have a reservoir to hold food so that it can gradually enter the
small intestine.  Instead, after a meal, the food may be “dumped” too quickly into the bowel.  This may
result in cramping and pain.  When sugars and starches that you have eaten are dumped into the
bowel, they may act like sponges, rapidly absorbing water from the body into the intestine.  This leads
to several symptoms including diarrhea, low blood sugar and feelings of weakness or dizziness

Nursing Management:

 Assess the family’s knowledge of preoperative and post-operative surgical routines and rationale
for surgery:
o Assess for the presence of bowel sounds
o Palpate the abdomen to detect masses and tenderness
 After surgery:
o Assess for complications secondary to surgical intervention such as:
- Hemorrhage
- Infection
- Abdominal distention
- Atelectasis
- Impaired nutritional status

Increased risk for:

 Hemorrhage
 Dietary deficiencies
 Bile reflux
 Dumping syndrome

Recognizing Obstacles to Adequate Nutrition:

Dumping Syndrome:

 As an unpleasant set of vasomotor and GI symptoms that sometimes occur in patients who have
had gastric surgery or a form of vagotomy.
 Foods high in carbohydrates and electrolytes must be diluted in the jejunum before absorption
can take place, but the passage of food from the stomach remnant into the jejunum is too rapid
to allow this to happen.
 The hypertonic intestinal contents draw extracellular fluid from the circulating blood volume
into the jejunum to dilute the high concentration of electrolytes and sugars.
  The ingestion of fluid at mealtime also causes the stomach contents to empty rapidly into the
jejunum

Early symptoms include:

 Sensation of fullness
 Weakness
 Faintness
 Dizziness
 Palpitations
 Diaphoresis
 Cramping pain
 Diarrhea

Anorexia may also be a result of the dumping syndrome, because the person may be reluctant to
eat.

Steatorrhea also may occur in the patient with gastric surgery.

- It is partially the result of rapid gastric emptying, which prevents adequate mixing with
pancreatic and biliary secretions. In mild cases, reducing the intake of fat and administering
an antimotility medication (eg, loperamide [Imodium]) may control steatorrhea.

Vitamin and Mineral Deficiencies:

 Other dietary deficiencies that the nurse should be aware of include malabsorption of
organic iron, which may require supplementation with oral or parenteral iron, and a low
serum level of vitamin B12, which may require supplementation by the intramuscular route.
 Total gastrectomy results in lack of intrinsic factor, a gastric secretion required for the
absorption of vitamin B12 from the GI tract. Unless this vitamin is supplied by parenteral
injection after gastrectomy, the patient inevitably suffers vitamin B12 deficiency, which
eventually leads to a condition identical to pernicious anemia.

All manifestations of pernicious anemia, including macrocytic anemia and combined system disease
(neurologic disorders of the central and peripheral nervous systems), may be expected to develop within
a period of 5 years or less; they progress in severity thereafter and, in the absence of therapy, are fatal.
This complication is avoided by the regular monthly intramuscular injection of vitamin B12. This regimen
should be started without delay after gastrectomy. Weight loss is a common long-term problem because
the patient experiences early fullness, which suppresses the appetite.

Monitoring and Managing Potential Complications

Hemorrhage complicates gastric surgery

 Usual signs of rapid blood loss

 May vomit considerable amounts of bright red blood.
  Assess NG drainage for type and amount. Some bloody drainage for the first 12 hours is
expected, but excessive bleeding should be reported.
 Assess the abdominal dressing bleeding.

Perform emergency measures such as:

 NG lavage
 Administration of blood and blood products along with hemodynamic monitoring