Anatomy Of The Stomach

The stomach is a sac-like organ located between the esophagus and small intestine. The stomach aids in
digestion and stores food. Anatomically, the stomach has been broken down into 5 different regions:
cardia, fundus, body, antrum, and pylorus (see below). The stomach is also composed of 5 different
tissue layers: mucosa, submucosa, muscularis, subserosa, and serosa. The more layers a cancer invades,
the worse its prognosis.

Gastric Cancer: Types

Listed below are some common and uncommon types of gastric cancer:

Gastric adenocarcinoma - The most common gastric cancer. It is usually divided into two subtypes:
intestinal and diffuse. Intestinal adenocarcinoma usually evolves in parts of the stomach closer to the
intestines and more frequently affects people over the age of 80. Diffuse adenocarcinoma is found more
often in young patients and those with blood type A. The diffuse form is what is traditionally considered
as gastric cancer.16

Gastrointestinal Stromal Tumor (GIST) - Uncommon. Arises from cells in the Cajal that regulate intestinal
contractions.7

Gastrointestinal Leiomyosarcoma - Uncommon. Rarely spreads to the lymph nodes. Arises from smooth
muscle cells in muscularis mucosa or propria of the stomach lining.7

Gastrointestinal Carcinoid - Uncommon. Arises from the mucosa in the gastric body and fundus. Limited
metastatic potential.8

Gastrointestinal lymphoma - Uncommon. Usually evolves in the stomach, but can start in any part of
gastrointestinal tract.

Gastric Cancer: Risk Factors

Factors that influence risk of developing stomach (gastric) cancer:

Helicobacter pylori infection

Diet

Gender

Age

Ethnicity

Geography

Smoking

Obesity

Previous stomach surgery

Pernicious anemia

Menetrier disease

Type A blood

Family history of stomach cancer

Occupations

Epstein-Barr infection

Some stomach polyps.

The relative effects of these and other risk factors in any given case of cancer is variable and very
difficult to determine with accuracy at this time. Some of these and other risk factors are discussed
below.

Helicobacter pylori infection

H. pylori is one of the most common bacterial infections worldwide. It causes duodenal and gastric
ulcers as well as chronic gastritis. H. pylori significantly increases the risk of developing gastric
adenocarcinoma. The World Health Organization classifies H. pylori as a class I carcinogen. It is found in
the stomach of over half of the world's population. The bacteria live in the mucosal lining of the stomach
and can cause chronic inflammation(gastritis). This inflammation can lead to DNA damage that promotes
cancer development. H. pylori is associated with over 70% of gastric adenocarcinomas.

Eradication of the infection is the best way to prevent gastric cancer. A combination of antibiotics,
stomach acid suppressors and stomach protectors may be used. Unfortunately, adequate diagnostic
tests and drug therapy for H. pylori eradication is very expensive. A vaccine would be a better approach
to the H. pylori problem. Vaccines have been moderately successful in animal models, but not in
humans. Several types of vaccines are currently being studied.10

Diet

An increase of fiber, raw fruit and vegetable consumption is associated with a significant decrease of
gastric cancer risk. Consumption of nitrates, refined carbohydrates (white bread, white rice, sugary
cereal, etc.) and highly salted or pickled foods is suspected to increase the risk for gastric cancer.10

Gender

Men are at higher risk than women for gastric cancer. This is especially true for the intestinal type of
cancer. It is thought that female reproductive hormones such as estrogen and progesterone help protect
against gastric cancer development.1112

Age

The risk for developing gastric cancer gradually increases after the age of 40. The diffuse type gastric
cancer occurs more often in younger patients whereas the intestinal type occurs more often in the
elderly. For this reason, age is a greater risk factor for the intestinal type than for the diffuse type.11

Ethnicity and Geography

Caucasians are at the lowest risk of developing gastric cancer and people of Asian descent are at the
highest risk. This disparity is mainly due to diet and living conditions. Japan and China have the highest
rates of gastric cancer and H. pylori infection. Eastern Europe is also at a higher risk than North America
and Western and Northern Europe.111

Smoking

Studies have shown that smoking increases risk for gastric cancer. Asian smokers have a higher risk for
developing intestinal type gastric cancer whereas Western smokers are at higher risk for diffuse type
gastric cancer.11

Family History of Gastric Cancer

Cancer cases can be grouped into two broad categories, sporadic and familial. Sporadic cancers are
those in which the affected individual does not have a known family history of the disease. Familial
cancers tend to occur in several generations of a family and affected individuals often have close
relatives (brother, sister, father) with the same type of cancer. It is possible that these individuals inherit
genes that increase risk for the development of specific cancers. Individuals with a family history of
gastric cancer are at an increased risk of developing the disease. The increase in risk depends upon the
type of relative affected. The more closely related an individual is to someone who has/had gastric
cancer, the more likely they will share the associated genes. Inherited gastric cancer accounts for about
1-3% of all stomach cancer cases13.

The major gastric cancer susceptibility syndrome is called hereditary diffuse gastric cancer (HDGC).
Other inherited forms of digestive system cancer include familial adenomatous polyposis (FAP) and
hereditary non-polyposis colorectal cancer (HNPCC)

TREATMENT

Surgery is the most common treatment option for early-stage gastric cancer. Three main surgical options
exist for gastric cancer:
Total gastrectomy - The surgical removal of the entire stomach

Partial or subtotal gastrectomy - The surgical removal of specific sections of the stomach

Resection - The surgical removal of a tumor and some surrounding tissue

The removal of the surrounding lymph nodes is frequently done during any type of surgery.
Chemotherapy and radiation therapy may also be used after surergy. Gastric cancer has a high
recurrence rate, so maintaining a healthy lifestyle and continuing medical surveillance after treatment
are important.

Because our focus is on the biology of the cancers and their treatments, we do not give detailed
treatment guidelines. Instead, we link to organizations in the U.S. that generate the treatment
guidelines.

The National Comprehensive Cancer Network (NCCN) lists the following treatments for gastric cancer:

Surgery

Radiation Therapy

Chemotherapy

Incidence and survival rates

Stomach cancer – also known as gastric cancer – is the fifth most common cancer worldwide. Around
952,000 new cases of stomach cancer were recorded globally in 2012, accounting for seven per cent of
all new cases of cancer.

Men are twice as likely as women to develop stomach cancer, and it is more common in older adults
over the age of 50. For example, the average age at diagnosis in the US is 72 years.
Stomach cancer is the third most common cause of death from cancer. Symptoms often only appear at a
late stage, which contributes to a poor prognosis. For example, in Europe and the US the five-year
survival rate of stomach cancer is about 25 to 28 per cent, increasing to about 63 per cent if the cancer
is diagnosed at an early stage. However, these survival rates are worse in less developed countries
where stomach cancer is typically detected at a more advanced stage.

About 70 per cent of cases of stomach cancer occur in less developed countries with about half of all
cases in Eastern Asia, particularly China.

Globally, overall incidence rates of stomach cancer are declining. This is attributed to a decrease in
Helicobacter pylori infection and the use of refrigeration to preserve foods rather than using salt.
Stomach cancer is classified into different types according to location of the tumour. Stomach cardia
cancer occurs at the top part of the stomach closest to the oesophagus, and stomach non-cardia cancer
occurs in all other areas of the stomach.

Stomach non-cardia cancer is more common than stomach cardia cancer, globally, and is most prevalent
in Asia. Rates of stomach non-cardia cancer are declining. Stomach cardia cancer is more common than
non-cardia cancer in more developed countries such as the UK and US, and is increasing in all countries.

RISK FACTORS

There is strong evidence that:

consuming alcoholic drinks INCREASES the risk of stomach cancer

consuming salt-preserved foods INCREASES the risk of stomach cancer

being overweight or obese INCREASES the risk of stomach cardia cancer

There is some evidence that:

consumption of grilled or barbecued meat and fish might increase the risk of stomach cancer

consumption of processed meat might increase the risk of stomach non-cardia cancer

consuming little or no fruit might increase the risk of stomach cancer

consumption of citrus fruit might decrease the risk of stomach cardia cancer

Other causes of stomach cancer

In addition to the findings on diet, nutrition and physical activity outlined above, other established
causes of stomach cancer include:

smoking

Smoking is a cause of stomach cancer. It is estimated that 11 per cent of cases worldwide are
attributable to tobacco use.

infection

Helicobacter pylori infection is a cause of stomach non-cardia cancer. Also, infection with Epstein-Barr
virus is under investigation as a contributor to stomach cancer.

industrial chemical exposure

Occupational exposure to dusty and high-temperature environments – such as woodprocessing and

food-machine operators – has been associated with an increased risk of stomach cancer. Other
industries including rubber manufacturing, coal mining, metal processing and chromium production
have also been associated with an elevated risk of this cancer.

What is stomach cancer?

Stomach cancer or gastric cancer is the growth of abnormal cells in the lining of the stomach. It is a
relatively rare type of cancer and patients seldom show any symptoms in the early phases, thereby
making it one of the most challenging malignancies to diagnose in stage 1.

There are four principal types of stomach cancer- adenocarcinomas, lymphoma, Gastrointestinal
Stromal Tumour (GIST) and carcinoid tumour.

Adenocarcinoma
It is the most common type of stomach cancer, approximately 90-95 per cent of gastric cancer falls
under this category. Here, the cells in the innermost lining of the stomach or mucosa multiply
abnormally to form a tumour.

Lymphoma

Lymphoma generally affects the immune system of an individual. In some cases, this type of cancer
develops on the walls of the stomach.

Gastrointestinal Stromal Tumour (GIST)

It is a rare form of stomach cancer which starts in the interstitial cells of Cajal in the stomach. Here,
some of the cells of a tumour are benign while others are malignant.

Carcinoid Tumour

This type of stomach cancer develops in the hormone-making cells of the stomach, and it is also known
as Gastrointestinal Carcinoid Tumors. The good thing about this cancer is it generally does not spread to
other organs.

How does stomach cancer occur?

The exact cause of stomach cancer is not known till date. Oncologists believe that an infection of
Helicobacter pyroli can be a probable reason for the development of stomach cancer. It causes ulcers in
the stomach which often become malignant in the future. In addition to this, gastritis (inflammation in
the stomach), pernicious anaemia (a type of long-lasting anaemia), and polyps in the gut may also cause
stomach cancer.

Like all other forms of cancer, Stomach Cancer has 4 stages.

Stage 0: In this stage, a collection of unhealthy cells develop in the inner lining of the patient’s stomach
which has a higher probability of becoming malignant in the future.

Stage 1: Here, the patient already has a small malignant tumour on the inner lining of the stomach. The
cancerous cells may spread to the nearby lymph nodes in stage 1.

Stage 2: In this stage, the malignant cells spread into the lymph nodes of the stomach as well as into the
deeper layers of the stomach wall.

Stage 3: Now, the cancerous cells are present in all the layers of the stomach as well as in some of the
adjacent organs like the spleen or colon.

Stage 4: This is the final stage of stomach cancer where the cancerous cells are present in many organs
like liver, lungs and even brain.

What are the complications of a stomach cancer?

If stomach cancer progresses to advanced stages, then it may lead to many complications like:

Gastrointestinal bleeding

Gastric perforation

Small Bowel Obstruction

What is the treatment for stomach cancer?

The cure for stomach cancer depends on how long the patient has been affected by the disease. If the
oncologist diagnoses the malignancy in the Stage 0 or Stage 1, then surgery is the best option to make
patient cancer free.

In Stage 2, the doctors proceed with an operation along with follow-up chemotherapy.
In stage 3, Chemotherapy is the main line of treatment. The doctors may also recommend complete
gastrectomy to remove the entire stomach along with chemoradiation to manage the disease or reduce
the discomforts.

In Stage 4, it is difficult to cure the disease. The doctors prescribe treatment to offer you relief from
complications, like the placement of a stent to remove the blockage of GI tract, or gastric bypass surgery
to create an alternate route for food passage around a tumour.

Making the Diagnosis

If a doctor suspects stomach cancer, a thorough patient history will first be done. This includes asking
about your lifestyle, such as tobacco or alcohol use and whether you have a family history of stomach
cancer. A physical exam may follow, along with some of the following tests:

blood tests

stool tests called fecal occult blood test – to find blood in the stool that might not be visible to the naked
eye

barium swallow or upper gastrointestinal (GI) series – the patient swallows a barium solution and the
doctor uses an X-ray to track the barium's progress as it passes through the esophagus and stomach

endoscopy – a small tube with a light on one end is slid down the throat and into the stomach so the
doctor can look directly at the stomach lining

biopsy – using a gastroscopy instrument that's fitted with a special cutter, a small piece of tissue can be
taken and examined under a microscope

If cancer is diagnosed, the doctor needs to determine the stage the cancer has reached. This may involve
more tests, such as:

chest X-rays

ultrasounds

computed tomography (CT) scans

magnetic resonance imaging (MRI) scans

PET scan

diagnostic laparoscopy

blood tests

NCP

Pain (acute) related to gastric erosion

Nursing Intervention

Monitor nutritional intake and weigh patient regularly.

Monitor CBC and serum vitamin B12 levels to detect anemia, and monitor albumin and prealbumin
levels to determine if protein supplementation is needed.

Provide comfort measures and administer analgesics as ordered.

Frequently turn the patient and encourage deep breathing to prevent pulmonary complications, to
protect skin, and to promote comfort.

Maintain nasogastric suction to remove fluids and gas in the stomach and prevent painful distention.

Provide oral care to prevent dryness and ulceration.

Keep the patient nothing by mouth as directed to promote gastric wound healing. Administer parenteral
nutrition, if ordered.

When nasogastric drainage has decreased and bowel sounds have returned, begin oral fluids and
progress slowly.

Avoid giving the patient high-carbohydrate foods and fluids with meals, which may trigger dumping
syndrome because of excessively rapid emptying of gastric contents.

Administer protein and vitamin supplements to foster wound repair and tissue building.

Eat small, frequent meals rather than three large meals.

Reduce fluids with meals, but take them between meals.

Stress the importance of long term vitamin B12 injections after gastrectomy to prevent surgically
induced pernicious anemia.
Encourage follow-up visits with the health care provider and routine blood studies and other testing to
detect complications or recurrence.

Discharge and Home Healthcare Guidelines

Teach the patient the importance of compliance with palliative and follow-up care. Be sure the patient
understands all medications, including the dosage, route, action, and adverse effects.

Teach the patient the signs and symptoms of infection and how to care for the incision. Instruct the
patient to notify the physician if signs of infection occur.

Encourage the patient to seek psychosocial support through local support groups (e.g.,I Can
Cope),clergy,or counseling services. If appropriate,suggest hospice services.

Teach the patient methods to enhance nutritional intake to maintain ideal body weight. Several small
meals a day may be tolerated better than three meals a day. Take liquid supplements and vitamins as
prescribed. Refer the patient to the dietitian for a consultation. Teach family members and friends
prevention strategies. Strategies include increasing the intake of fresh fruits and vegetables that are high
in vitamin C; maintaining adequate protein intake; and decreasing intake of salty, starchy, smoked, and
nitrite- preserved foods.