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Gastric Cancer 417

Gastric Cancer DRG Category: 326

Mean LOS: 15.4 days
Description: SURGICAL: Stomach, Esophageal,
and Duodenal Procedure With
Major CC
DRG Category: 375
Mean LOS: 5.5 days
Description: MEDICAL: Digestive Malignancy
With CC

Gastric cancer is a relatively uncommon malignancy, accounting for approximately 2% of

all cancers in the United States. While reports vary, the World Health Organization states that
it is the sixth-most common cancer worldwide. Because it is often found in advanced stages
both in developed and developing regions of the world, it is difficult to cure. In 2013 in the
United States, it was estimated that 21,600 people were diagnosed with gastric cancer and that
10,990 died of the disease. This type of cancer, like lung cancer, is primarily found in the
seventh decade of life.
Nearly 95% of gastric neoplasms are classified as adenocarcinomas; these tumors develop
from the epithelial cells that form the innermost lining of the stomach’s mucosa. The most
common sites for cancer in the stomach include the antrum, the pylorus, and along the area of
lesser curvature. According to the Lauren classification, gastric adenocarcinomas are divided
into two main histologic types: diffuse and intestinal. The diffuse type is ill defined, infiltrates
the gastric wall, and lacks a distinctive mass. The intestinal type, by contrast, is composed of
neoplastic cells that cluster together, resembling glands; it is associated with a better prognosis,
as are tumors along the area of lesser curvature. A poor prognosis is associated with tumors of
the cardia or the fundus.
Metastasis occurs via the lymphatics and the blood vessels by seeding of peritoneal surfaces
or by direct extension of the tumor. Sites of metastasis are the liver, lungs, bone, adrenals, brain,
ovaries, colon, and pancreas. Intestinal tumors are more likely to spread to the liver, whereas
diffuse-type tumors are more likely to spread along peritoneal surfaces. Other complications
include malnutrition, gastrointestinal (GI) obstruction, and iron deficiency anemia.

CAUSES
A probable factor in developing gastric cancer is a Helicobacter pylori infection leading to
atrophic gastritis (inflammation and damage to the inner layer of the stomach). Dietary factors
linked to gastric cancer are associated with either gastric irritation or exposure to mutagenic or
carcinogenic compounds. They include a high intake of smoked foods, salted fish and meat,
nitrite-preserved foods, starch, and fat, along with a low intake of fruits, vegetables, and animal
proteins. Associated environmental factors include exposure to ionizing radiation and being em-
ployed in metal products or chemical industries. Physiological factors are related to a rise in gastric
pH or the formation of mutagenic or carcinogenic compounds. Other associated conditions include
gastric ulcers, gastric polyps, pernicious anemia, intestinal metaplasia, achlorhydria, hypochlor-
hydria, gastric atrophy, and chronic peptic ulcers. Similarly, patients who have undergone a partial
gastrectomy for benign gastric disease are predisposed to developing gastric cancer.

GENETIC CONSIDERATIONS
Genetic factors that are linked to an increased incidence of gastric cancer include a family
history of stomach cancer and type A blood. There is a familial cancer syndrome with an
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418 Gastric Cancer

autosomal dominant pattern of transmission identified as hereditary diffuse gastric cancer. Mu-
tations in the gene E-cadherin/CDH1 are associated with this disease. Family history has also
been associated with gastric cancer, with the risk of gastric cancer having a two-fold increase
when a first-degree relative is affected.

GENDER, ANCESTRY, AND LIFE SPAN CONSIDERATIONS

Two-thirds of the patients with gastric cancer are older than 65. More men than women die of
gastric cancer. Rates for gastric cancer are higher in Asian countries.

GLOBAL HEALTH CONSIDERATIONS

Gastric cancer is the sixth-most common cancer worldwide (after breast, prostate, lung, colo-
rectal, and cervical cancers). It has rates as high as 80 per 100,000 individuals per year in
Southeastern Asia, South America, and some Eastern European countries. Developed nations
have more than twice the incidence of gastric cancer than developing nations.

ASSESSMENT
HISTORY. Gastric cancer may not produce symptoms until the disease is very advanced. About
one-third of the patients report a long history of dyspepsia (painful digestion). The most common
initial symptoms are mild epigastric discomfort, loss of appetite, nausea, and a sense of
fullness or gas pains. Patients may also report experiencing unusual tiredness, abdominal pains,
constipation, weight loss, and a bad taste in the mouth. Massive GI bleeding is unusual, although
chronic bleeding may occur, which results in a positive occult blood test. Patients with advanced
gastric cancer report the classic symptoms of anemia, such as fatigue and activity intolerance,
as well as vomiting (coffee ground or sometimes containing frank blood), anorexia, abdominal
pain, dyspepsia, and dysphagia (difficulty swallowing).

PHYSICAL EXAMINATION. In the early stages of gastric cancer, the patient usually appears
healthy. The most common initial symptoms are mild epigastric discomfort, loss of appetite,
nausea, and a sense of fullness or gas pains. In later stages, patients may appear weak, pale,
dyspneic, and fatigued from anemia; they are thin and seem to be malnourished. Only 37% of
patients have a palpable abdominal mass. Observe for abdominal swelling and ascites (poor
prognostic sign) and palpate for hepatomegaly secondary to liver or peritoneal metastases. Some
patients may have palpable lymph nodes, especially the supraclavicular and axillary nodes.
Gastric cancer is frequently staged using the TNM classification system (T: primary tumor,
N: lymph node, M: distant metastasis).

PSYCHOSOCIAL. Survival rates after treatment for gastric cancer remain discouraging (the
5-year survival rate is 27% for all gastric cancers), and patients with gastric cancer have special
psychosocial concerns. Assess their support systems and their ability to cope with major lifestyle
changes. As appropriate, assess their transition through the various stages of death and dying.

Diagnostic Highlights
General Comments: The presence of lactic acid and a high lactate dehydrogenase
level in the gastric juice are suggestive of cancer. Often, in patients with gastric cancer,
plasma tumor markers (carcinoembryonic antigen [CEA], cancer antigent [CA] 19– 9) are
elevated. Positive fecal occult blood tests are associated with the chronic bleeding that
is related to gastric cancer.
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Gastric Cancer 419

Diagnostic Highlights (continued)

Abnormality With
Test Normal Result Condition Explanation
Upper GI series Normal upper GI Presence of cancer in the Identifies size and location of
tract stomach tumor
Esophagogastro- Normal stomach Visualization of cancer in Visualizes tumor for biopsy; has
duodenoscopy the stomach a diagnostic accuracy of 95%

Other Tests: Cytology studies of the specimens obtained, computed tomography scan,
abdominal ultrasonography, and laparoscopy; complete blood count, CEA, CA 19– 9

PRIMARY NURSING DIAGNOSIS

DIAGNOSIS. Pain (acute) related to gastric erosion
OUTCOMES. Comfort level; Pain control behavior; Pain level; Symptom severity
INTERVENTIONS. Analgesic administration; Anxiety reduction; Environmental management:
Comfort; Pain management; Medication management; Patient-controlled analgesia assistance

PLANNING AND IMPLEMENTATION

Collaborative
Treatment includes surgery, chemotherapy, and radiation. Of patients with potentially curable gastric
cancer, 80% die from a recurrence within 5 years of the initial treatment. If the cancer is resected
before it has invaded the stomach wall, the 5-year survival rate is about 90%. The deeper the cancer
invades the stomach wall, the poorer the prognosis. A complete en bloc resection of an early, localized
tumor is the only cure. Most patients undergo a subtotal gastrectomy, after which GI continuity can
be restored by either a Billroth I (gastroduodenostomy) or a Billroth II (gastrojejunostomy) procedure.
After such gastric surgery, patients are prone to vitamin B12 deficiency and megaloblastic anemia
from lack of intrinsic factor; monthly vitamin B12 replacement is therefore necessary. For patients
who undergo a Billroth I procedure, postprandial dumping syndrome is a problem. For patients who
undergo a Billroth II procedure, postoperative intestinal obstruction is a concern. In addition, trans-
fusions of packed red blood cells are given to patients to correct anemia.
For patients with advanced disease, palliative subtotal or total gastrectomies may be per-
formed to alleviate gastric symptoms, such as bleeding or obstruction. After surgery, chemo-
therapy or radiation, or both, may be provided.

Pharmacologic Highlights
Medication or
Drug Class Dosage Description Rationale
Chemotherapeutic Varies with drug Used as adjuvant (in addition Treat cancer that has me-
agents to) or neoadjuvant (before sur- tastasized to organs be-
gery) often in combination: flu- yond stomach; shrink tu-
orouracil, doxorubicin, methyl- mors before surgery
1-(2-Chloroethyl)-3-Cyclohexyl-
1-Nitrosourea (CCNU), cispla-
tin, methotrexate, etoposide;
Trastuzumab combined with
cisplatin and capecitabine or 5-
FU (for people who have not
have previous chemotherapy)
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420 Gastric Cancer

Pharmacologic Highlights (continued)

Medication or
Drug Class Dosage Description Rationale
Vitamins Tablets come in Vitamin B complex Combat vitamin B12 defi-
various sizes ciency and megaloblastic
anemia from lack of intrin-
sic factor
Narcotic analge- Varies with drug Manage pain, side effects of Increase patient comfort
sics treatment drugs such as mor- during end-stage disease
phine, meperidine

Other Drugs: Antiemetics may be used to control nausea, which increases as the tumor
enlarges. In the advanced stages, the physician may prescribe sedatives, narcotics, and
tranquilizers to increase the patient’s comfort. Antispasmodics and antacids may also
help relieve GI discomfort.

Independent
PREOPERATIVE. Explain all preoperative and postoperative procedures. Preoperative needs
include nutritional adequacy, intravenous fluids, and prophylactic bowel preparation. Inform
the patient about the need for GI decompression via a tube for 1 to 3 weeks postoperatively.
Explain the amount of pain that should be anticipated and reassure the patient that analgesia
provides relief. Teach coughing and deep-breathing exercises and have the patient practice them.
POSTOPERATIVE. Maintain wound care, provide adequate fluid and nutrition, manage pain,
and control symptoms. Monitor the patient for complications such as hemorrhage, intestinal
obstruction, and infection. Teach wound care and the signs and symptoms of infection. Teach
nonpharmacologic pain management techniques. As indicated, teach the signs and symptoms
of “dumping syndrome”: epigastric fullness, nausea, vomiting, abdominal cramping, and diar-
rhea that occur within 30 minutes of eating. Teach patients that they may also experience
sweating, dizziness, pallor, and palpitations related to the dumping syndrome. To relieve the
symptoms, teach patients to avoid drinking fluids within a half hour of meals and to eat small
meals that are low carbohydrate, high fat, and high protein.

Evidence-Based Practice and Health Policy

Ma, J.L., Zhang, L., Brown, L.M., Li, J.Y., Shen, L., Pan, K.F., . . . Gail, M.H. (2012). Fifteen-
year effects of Helicobacter pylori, garlic, and vitamin treatments on gastric cancer incidence
and mortality. Journal of the National Cancer Institute, 104(6), 488– 492.
• Investigators conducted a randomized controlled trial to determine the effects of a 2-week
treatment regimen with amoxicillin and omeprazole and a 7-year vitamin C, E, and selenium
supplement regimen on decreasing the risk of gastric cancer among patients who tested pos-
itive for H. pylori. Amoxicillin and omeprazole treatments were given to 1,130 patients, and
the placebo was given to 1,128 patients. Vitamin treatments were given to 1,677 patients, and
the placebo was given to 1,688 patients.
• Over the course of the 14.7 follow-up years, gastric cancer was diagnosed in 3% of the
amoxicillin and omeprazole treatment group and 4.6% of the placebo group. Treatment with
amoxicillin and omeprazole decreased the risk of gastric cancer by 39% (95% CI, 0.38 to
0.96; p ⫽ 0.032).
• Vitamin supplementation did not decrease the risk of gastric cancer, as 2.9% of the vitamin
treatment group was diagnosed compared to 3.4% of the vitamin placebo group. However,
vitamin treatment was associated with a 49% decreased risk of mortality from gastric cancer
(95% CI, 0.30 to 0.87; p ⫽ 0.014).
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Gastritis 421

DOCUMENTATION GUIDELINES
• Physical findings related to gastric cancer: Epigastric discomfort, dyspepsia, anorexia, nausea,
sense of fullness, gas pains, unusual tiredness, abdominal pains, constipation, weight loss,
vomiting, hematemesis, blood in the stool, dysphagia, jaundice, ascites, bone pain
• GI decompression data: Irrigation and patency of tube, assessment of bowel sounds and pas-
sage of gas, complaints of nausea, amount and description of gastric fluid output
• Presence of postoperative complications: Hemorrhage, obstruction, anastomotic leaks, infec-
tion, peritonitis
• Presence of postoperative dumping syndrome and associated patient symptoms

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 psycho-
social 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 increas-
ing 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.

Gastritis DRG Category: 391

Mean LOS: 5.1 days
Description: MEDICAL: Esophagitis,
Gastroenteritis, and Miscellaneous
Digestive Disorders With Major CC

Gastritis is any inflammatory process of the mucosal lining of the stomach. The inflammation
may be contained within one region or be patchy in many areas. Gastric structure and function
are altered in either the epithelial or the glandular components of the gastric mucosa. The
inflammation is usually limited to the mucosa, but some forms involve the deeper layers of the
gastric wall. Gastritis is classified into acute and chronic forms.
ACUTE. The most common form of acute gastritis is acute hemorrhagic gastritis, also called
acute erosive gastritis. The gastric erosions are limited to the mucosa, which have edema and
sites of bleeding. Erosions can be diffuse throughout the stomach or localized to the antrum.
Acute nonerosive gastritis is usually caused by Helicobacter pylori, which can also lead to
chronic gastritis.
CHRONIC. The three forms of chronic inflammation of the gastric mucosa are superficial
gastritis, atrophic gastritis, and gastric atrophy. Superficial gastritis, the initial stage in the de-
velopment of chronic gastritis, leads to red, edematous surface epithelium; small erosions; and
decreased mucus content. The gastric glands remain normal. With atrophic gastritis, inflam-
mation extends deeper into the gland area of the mucosa with loss of parietal and chief cells.
Atrophic gastritis further develops into the final stage of chronic gastritis— gastric atrophy. In
this stage, there is a total loss of glandular structure.
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