DIPOLOG MEDICAL CENTER COLLEGE FOUNDATION INC.

College of Nursing

A
CASE STUDY
OF
GASTRIC CANCER

Submitted by:
Tiffany Luv B. Adrias
BSN III - Orlando

Submitted to:
Maridol Claro
INSTRUCTOR
 CONTENTS

A. Introduction

B. Terminologies

C. Anatomy and Physiology

D. Pathophysiology

E. Nursing Care Plan

F. Discharge Instructions (Methods) Style

G. Drug Study

H. Readings r/t Digestive cases / Articles Summary and Reaction

I. General Evaluation including Laboratory / Diagnostic Tests

INTRODUCTION
Description

 It is also called malignant tumor of the stomach.

 It is usually an adenocarcinoma.
 It spreads rapidly to the lungs, lymph nodes, and liver.
 Risk factors include chronic atrophic gastritis with intestinal metaplasia;
pernicious anemia or having had gastric resections (greater than 15 years
prior); and adenomatous polyps.
 This cancer is most common in men older than age 40 and in blacks.
 Complications are hemorrhage and dumping syndrome from surgery or
widespread metastasis and death.

Risk Factors
No one knows why some people develop stomach cancer and others don’t. The
number of people affected varies widely between different countries. For example,
stomach cancer is far more common in Japan than in the UK. There is also evidence
that people from poorer backgrounds are at increased risk.

 Age. Stomach cancer is most common around the age of 60. It’s rare under the age of 40.
 Gender. Men are around twice as likely to develop stomach cancer as women.
 Helicobacter pylori infection. These bacteria live in the stomach lining of many people, and
don’t usually cause any symptoms. However, the infection sometimes causes inflammation of
the stomach lining (gastritis), indigestion and stomach ulcers. It is known to increase the risk of
stomach cancer.
 Diet. A diet high in salt and foods that are smoked or cured may increase the risk of stomach
cancer. In particular, certain food preservative chemicals known as nitrosamines, which are
found cured meats such as bacon and ham, may increase your chance of developing stomach
cancer.
 Family history. Some people inherit an increased risk of developing stomach cancer.
 Type A blood group. Some research indicates that people who have type A blood are at
higher risk of developing stomach cancer.
 Smoking. When you smoke, you swallow small amounts of tobacco smoke, which increases
your risk of getting stomach cancer.
 Atrophic gastritis. This condition causes the lining of the stomach to waste away. It has also
been linked with an increased risk of stomach cancer.
 Pernicious anaemia. This is type of anaemia raises your risk of stomach cancer.
TERMINOLOGIES

Atrophic gastritis - a histopathologic entity characterized by chronic inflammation of

the gastric mucosa with loss of the gastric glandular cells and replacement by intestinal-

type epithelium, pyloric-type glands, and fibrous tissue.

Dyspepsia - also known as indigestion, refers to discomfort or pain that occurs in the

upper abdomen, often after eating or drinking.

Dysplasia - A term used to describe the presence of abnormal cells within a tissue or

organ.

Gastritis - a condition that inflames the stomach lining (the mucosa), causing belly pain,

indigestion (dyspepsia), bloating and nausea.

Intestinal Metaplasia - a condition in which the cells that create the lining of your

stomach are changed or replaced.

 ANATOMY AND PHYSIOLOGY

Stomach
The stomach is a muscular, J-shaped organ in the upper part of the abdomen. It is part of
the digestive system, which extends from the mouth to the anus. The size of the stomach
varies from person to person, and from meal to meal.
Structure
The stomach is part of the digestive system and is connected to the:
 Esophagus – a tube-like organ that connects the mouth and throat to the stomach. The
area where the esophagus joins the stomach is called the gastroesophageal (GE)
junction.
 Small intestine (small bowel) – a long tube-like organ that extends from the stomach to
the colon (large intestine or large bowel). The first part of the small intestine is called
the duodenum, and it is this part that is connected to the stomach.
 The stomach is surrounded by a large number of lymph nodes.
 The stomach is divided into 5 regions:
 The cardia is the first part of the stomach below the esophagus. It contains the cardiac
sphincter, which is a thin ring of muscle that helps to prevent stomach contents from
going back up into the esophagus.
 The fundus is the rounded area that lies to the left of the cardia and below
the diaphragm
 The body is the largest and main part of the stomach. This is where food is mixed and
starts to break down.
 The antrum is the lower part of the stomach. The antrum holds the broken-down food
until it is ready to be released into the small intestine. It is sometimes called the pyloric
antrum.
 The pylorus is the part of the stomach that connects to the small intestine. This region
includes the pyloric sphincter, which is a thick ring of muscle that acts as a valve to
control the emptying of stomach contents (chyme) into the duodenum (first part of the
small intestine). The pyloric sphincter also prevents the contents of the duodenum from
going back into the stomach.

Layers of the stomach wall

 The mucosa (mucous membrane) is the inner lining of the stomach. When the stomach is
empty the mucosa has a ridged appearance. These ridges (rugae) flatten out as the
stomach fills with food.
 The next layer that covers the mucosa is the submucosa. It is made up of connective tissue
that contains larger blood and lymph vessels, nerve cells and fibres.
 The muscularis propria (or muscularis externa) is the next layer that covers the submucosa.
It is the main muscle of the stomach and is made up of 3 layers of muscle.
 The serosa is the fibrous membrane that covers the outside of the stomach. The serosa of
the stomach is also called the visceral peritoneum

Function
The stomach has 3 main functions:
o temporary storage for food, which passes from the esophagus to the stomach where it
is held for 2 hours or longer
 o mixing and breakdown of food by contraction and relaxation of the muscle layers in
the stomach
o digestion of food
 The mucosa contains specialized cells and glands that produce hydrochloric acid and
digestive enzymes to help digest food. The mucosa in the cardiac and pyloric regions of
the stomach release mucus that helps protect the lining of the stomach from the acid
produced for digestion. Other specialized cells in the mucosa of the pylorus release
the hormone gastrin into the blood. Gastrin helps to stimulate the release of acid and
enzymes from the mucosa. Gastrin also helps the muscles of the stomach to start
contracting.
 Food is broken down into a thick, acidic, soupy mixture called chyme. The pyloric sphincter
relaxes once chyme formation is complete. Chyme then passes into the duodenum. The
duodenum plays a big role in absorption of the food we eat. The stomach does not play a
big role in absorption of food. It only absorbs water, alcohol and some drugs.

.
 PATHOPHYSIOLOGY

NORMAL

DIET FACTORS
(LOW IN VITAMIN C & E, H. PYLORI INFECTION
HIGH SALT DIET)

CHRONIC SUPERFICIAL GASTRITIS

ATROPHIC GASTRITIS

INTESTINAL METAPLASIA

DYSPLASIA

CANCER
 NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Review patient’s and
Objective: Acute Pain After 8 hours of SO’s previous After 8 hours of
related to the nursing experience with cancer. nursing interventions,
presence of interventions, the Determine what the the patient was able to
abnormal patient will report doctor has told patient report no pain and less
epithelial cells, no pain and less and what conclusion discomfort
nerve impulse discomfort. patient has reached.
disorders of the Encourage patient to
stomach. share thoughts and
feelings.
Provide open
environment in which
patient feels safe to
discuss feelings or to
refrain from talking.
Maintain frequent
contact with patient. Talk
with and touch patient as
appropriate.
Be aware of effects of
isolation on patient when
required by
immunosuppression or
radiation implant. Limit
use of isolation clothing
and masks as possible.
Assist patient and SO in
recognizing and
clarifying fears to begin
developing coping
strategies for dealing
with these fears.
Provide accurate,
consistent information
regarding
diagnosis and prognosis.
Avoid arguing about
patient’s
perceptions of situation.
8. Permit expressions of
anger, fear, despair
without confrontation.
Give information that
DISCHARGE INSTRUCTIONS (METHODS)

Medicines:

 You may need any of the following:

o Antinausea medicine may be given to calm your stomach and prevent
vomiting.
o Prescription pain medicine may be given. Ask your healthcare provider how
to take this medicine safely. Some prescription pain medicines contain
acetaminophen. Do not take other medicines that contain acetaminophen
without talking to your healthcare provider. Too much acetaminophen may
cause liver damage. Prescription pain medicine may cause constipation. Ask
your healthcare provider how to prevent or treat constipation.
o Blood thinners help prevent blood clots. Clots can cause strokes, heart
attacks, and death. The following are general safety guidelines to follow
while you are taking a blood thinner:
o Watch for bleeding and bruising while you take blood thinners. Watch for
bleeding from your gums or nose. Watch for blood in your urine and bowel
movements. Use a soft washcloth on your skin, and a soft toothbrush to brush
your teeth. This can keep your skin and gums from bleeding. If you shave,
use an electric shaver. Do not play contact sports.
o Tell your dentist and other healthcare providers that you take a blood
thinner. Wear a bracelet or necklace that says you take this medicine.
o Do not start or stop any other medicines unless your healthcare provider tells
you to. Many medicines cannot be used with blood thinners.
o Take your blood thinner exactly as prescribed by your healthcare provider.
Do not skip does or take less than prescribed. Tell your provider right away
if you forget to take your blood thinner, or if you take too much.
o Warfarin is a blood thinner that you may need to take. The following are
things you should be aware of if you take warfarin:
 o Foods and medicines can affect the amount of warfarin in your blood. Do
not make major changes to your diet while you take warfarin. Warfarin
works best when you eat about the same amount of vitamin K every day.
Vitamin K is found in green leafy vegetables and certain other foods. Ask
for more information about what to eat when you are taking warfarin.
o You will need to see your healthcare provider for follow-up visits when you
are on warfarin. You will need regular blood tests. These tests are used to
decide how much medicine you need.
 Take your medicine as directed. Contact your healthcare provider if you think your
medicine is not helping or if you have side effects. Tell him or her if you are
allergic to any medicine. Keep a list of the medicines, vitamins, and herbs you take.
Include the amounts, and when and why you take them. Bring the list or the pill
bottles to follow-up visits. Carry your medicine list with you in case of an
emergency.

Do not smoke:
 Nicotine can damage blood vessels and make it more difficult to manage stomach
cancer. Smoking also increases your risk for new or returning cancer and delays
healing after treatment. Do not use e-cigarettes or smokeless tobacco in place of
cigarettes or to help you quit. They still contain nicotine. Ask your healthcare
provider for information if you currently smoke and need help quitting.

Do not drink alcohol:

 Alcohol can cause more stomach damage.

Nutrition:

 If you had surgery to remove part of your stomach, you may need to follow a
special diet. This may decrease symptoms, such as dumping syndrome (food
passing too quickly through your stomach and into your intestines). A dietitian may
work with you to help reduce symptoms.
Drink liquids as directed:
 Ask how much liquid to drink each day and which liquids are best for you. Drink
extra liquids to prevent dehydration. You will also need to replace fluid if you are
vomiting or have diarrhea from cancer treatments.

Exercise as directed:
 Exercise can help increase your energy level and appetite. Ask your healthcare
provider how much exercise you need and which exercises are best for you.

Call your local emergency number for any of the following:

 You suddenly feel lightheaded and short of breath.
 You have chest pain when you take a deep breath or cough.
 You cough up blood.

Seek care immediately if:

 Your arm or leg feels warm, tender, and painful. It may look swollen and red.
 You are vomiting and cannot keep food or liquids down.
 You are dizzy or feel confused.

Call your doctor or oncologist if:

 Your pain is worse or does not go away after you take pain medicine.
 You have a fever.
 You have questions or concerns about your condition or care.

Follow up with your doctor or oncologist as directed:

 You will need to see your oncologist for ongoing tests and treatment. Write down
your questions so you remember to ask them during your visits.
 DRUG STUDY

Mechanism of
Drug Indications Contraindications Side effects
Action
Generic Name: Ramucirumab binds CYRAMZA®, as a  Anticoagulant Single agent
with high affinity to the single agent or in therapy, bleeding,  Hypertension
Ramucirumab
extracellular domain of combination with GI bleeding, GI  Diarrhea
Brand Name: vascular endothelial paclitaxel, is perforation Combination therapy
Cyramza
growth factor receptor indicated for the  Impaired wound  Fatigue/asthenia
2 (VEGFR2; kinase treatment of healing, surgery  Neutropenia
Classification: insert domain- patients with  Infusion-related  Neutropenia, Grade
containing receptor; advanced or reactions 3-4
Monoclonal
KDR), preventing the metastatic, gastric  Cardiac arrest,  Diarrhea
antibody binding of ligands or gastro- myocardial  Epistaxis
VEGF-A, VEGF-C, esophageal infarction, stroke  Peripheral edema
and VEGF-D. As a junction (GEJ)  Hypertension  Hypertension
result, ramucirumab adenocarcinoma  Biliary cirrhosis,  Stomatitis
inhibits ligand- with disease hepatic disease  Proteinuria
stimuluated activation progression on or  Human anti-human Hypertension,
of VEGFR2, inhibiting after prior antibody (HAHA) Grade 3-4
ligand-induced fluoropyrimidine-
 Proteinuria, renal  Thrombocytopenia
proliferation, and or platinum-
disease  Fatigue/asthenia,
migration of human containing Grade 3-4
 Breast-feeding
endothelial cells. chemotherapy.  Hypoalbuminemia
Ramucirumab  Encephalopathy
inhibited angiogenesis  Hypothyroidism,
in an in vivo animal thyroid disease
model. Ramucirumab  Pregnancy
works differently than  Contraception
bevacizumab, another requirements,
VEGF inhibitor, in that infertility,
bevacizumab binds to pregnancy testing,
the ligand, VEGF, reproductive risk
preventing it from
binding to
VEGFR2/KDR;
 bevacizumab also
decreases VEGF
levels after binding.
Ramucirumab binds to
VEGF2, preventing
the VEGF ligands
from binding, and
does not affect initial
levels of VEGF. The
mechanism of binding
to VEGFR2 rather
than VEGF may also
induce less
resistance, since
endothelial cells are
genetically stable.

Mechanism of Nursing
Drug Indications Contraindications Side effects
Action considerations
Generic Name: Trastuzumab binds to Indicated, in Concurrent Body as a Whole: Pain,  Lab tests:
the extracellular combination with administration of asthenia, fever, chills, flu Periodically monitor
Trastuzumab
juxtamembrane cisplatin and anthracycline or syndrome, allergic CBC with differential,
Brand Name: domain of HER2 and capecitabine or 5- radiation; lactation reaction, bone pain, platelet count, and
inhibits the fluorouracil, for the during and for 6 mo arthralgia, hypersensitivity Hgb and Hct.
Herceptin
proliferation and treatment of patients following (anaphylaxis, urticaria,  Monitor for chills and
Classification: survival of HER2- with HER2- administration of bronchospasm, fever during the first
dependent tumors. It overexpressing trastuzumab. angioedema, or IV infusion; these
Antineoplastics,
is approved by the metastatic gastric or hypotension), increased adverse events
Anti-HER2 Food and Drug gastroesophageal incidence of infections, usually respond to
Administration (FDA) junction infusion reaction (chills, prompt treatment
for patients with adenocarcinoma who fever, nausea, vomiting, without the need to
invasive breast have not received pain, rigors, headache, discontinue the
cancers that prior treatment for dizziness, dyspnea, infusion. Notify
overexpress HER2. metastatic disease. hypotension, rash). physician
CNS: Headache, immediately.
insomnia, dizziness,  Monitor carefully
paresthesias, depression, cardiovascular status
peripheral neuritis, at baseline and
neuropathy. throughout course of
CV: CHF, cardiac therapy, assessing
dysfunction (dyspnea, for S&S of heart
cough, paroxysmal failure (e.g.,
nocturnal dyspnea, dyspnea, increased
peripheral edema, S3 cough, PND, edema,
gallop, reduced ejection S3 gallop). Those
fraction), tachycardia, with preexisting
edema, cardiotoxicity. cardiac dysfunction
GI: Diarrhea, abdominal are at high risk for
pain, nausea, cardiotoxicity.
vomiting, anorexia.
Hematologic: Anemia,
leukopenia.
Respiratory: Cough,
dyspnea, rhinitis,
pharyngitis, sinusitis.
Skin: Rash, herpes
simplex, acne.
READINGS R/T DIGESTIVE CASES / ARTICLES SUMMARY AND REACTIONS
 GENERAL EVALUATION INCLUDING LABORATORY OR DIAGNOSTIC
TESTS

In addition to a physical examination, the following tests may be used to diagnose stomach
cancer:

 Biopsy. A biopsy is the removal of a small amount of tissue for examination under a
microscope. Other tests can suggest that cancer is present, but only a biopsy can make
a definite diagnosis. A pathologist then analyzes the sample(s). A pathologist is a
doctor who specializes in interpreting laboratory tests and evaluating cells, tissues,
and organs to diagnose disease.
 Molecular testing of the tumor. Your doctor may recommend running laboratory tests
on a tumor sample to identify specific genes, proteins, and other factors unique to the
tumor. Results of these tests can help determine your treatment options.
 For stomach cancer, testing may be done for PD-L1 and high microsatellite instability
(MSI-H), which may also be called a mismatch repair deficiency. Testing can also be
done to determine if the tumor is making too much of a protein called human
epidermal growth factor receptor 2 (HER2), particularly if the cancer is more
advanced. The results of these tests help doctors find out if immunotherapy is a
treatment option.
 Endoscopy. An endoscopy allows the doctor to see the inside of the body with a thin,
lighted, flexible tube called a gastroscope or endoscope. The person may be sedated
as the tube is inserted through the mouth, down the esophagus, and into the stomach
and small bowel. Sedation is giving medication to become more relaxed, calm, or
sleepy. The doctor can remove a sample of tissue as a biopsy during an endoscopy
and check it for signs of cancer.
 Endoscopic ultrasound. This test is similar to an endoscopy, but the gastroscope has a
small ultrasound probe on the end. An ultrasound uses sound waves to create a picture
of the internal organs. An ultrasound image of the stomach wall helps doctors
determine how far the cancer has spread into the stomach and nearby lymph nodes,
tissue, and organs, such as the liver or adrenal glands.
 X-ray. An x-ray is a way to create a picture of the structures inside of the body using
a small amount of radiation.
 Barium swallow. In a barium swallow, a person swallows a liquid containing barium,
and a series of x-rays are taken. Barium coats the lining of the esophagus, stomach,
and intestines, so tumors or other abnormalities are easier to see on the x-ray.
 Computed tomography (CT or CAT) scan. A CT scan takes pictures of the inside of the
body using x-rays taken from different angles. A computer combines these pictures
into a detailed, 3-dimensional image that shows any abnormalities or tumors. A CT
scan can be used to measure the tumor’s size. Sometimes, a special dye called a
contrast medium is given before the scan to provide better detail on the image. This
dye is usually given both as a liquid to swallow and an injection into a patient's vein.
 Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to
produce detailed images of the body. MRI can be used to measure the tumor’s size. A
special dye called a contrast medium is given before the scan to create a clearer
picture. This dye is usually injected into a patient’s vein.
 Positron emission tomography (PET) or PET-CT scan. A PET scan is usually combined
with a CT scan (see above), called a PET-CT scan. However, you may hear your doctor
refer to this procedure just as a PET scan. A PET scan is a way to create pictures of
organs and tissues inside the body. A small amount of a radioactive sugar substance is
injected into the patient’s body. This sugar substance is taken up by cells that use the
most energy. Because cancer tends to use energy actively, it absorbs more of the
radioactive substance. A scanner then detects this substance to produce images of the
inside of the body.
 Laparoscopy. A laparoscopy is a minor surgery in which the surgeon inserts a thin,
lighted, flexible tube called a laparoscope into the abdominal cavity. It is used to find
out if the cancer has spread to the lining of the abdominal cavity or liver. A CT or PET
scan cannot often find cancer that has spread to these areas.