STOMACH AND ABDOMINAL LUMP

A middle aged gentleman presents with profuse haematemesis

following analgesic intake. How will investigate and manage this
patient? What are the complication of chronic peptic ulcer? 5+5+5 (2020
regular; P-1)
Complications of Chronic Peptic Ulcer
Gastric Ulcer Duodenal Ulcer
 Hour glass contracture  Pyloric stenos is (10%): Due to
 Tea-pot deformity(Hand-bag scarring and cicatrisation of first
stomach) part of the duodenum.
 Perforation-most frequent.  Bleeding
 Bleeding by erosion into the left  Perforation
gastric  Residual abscess.
 Penetration posteriorly into  Penetration to pancreas
pancreas, anteriorly into liver.  Intractability: It is an ulcer that has
 Malignant transformation usually not healed after 8 weeks of full-
into adenocarcinoma of stomach dose treatment

A 45 year old man presented with a recently discovered lump in the

epigastrium with rapidly developing anorexia, asthenia, anaemia and
increasing vomiting. How would you investigate to arrive at diagnosis?
Outline the management of the case. 8+7 (2016 regular; P-1)

See answer

Describe the clinical features, investigations and management of

carcinoma of stomach. 4+4+7 (2014 regular; P-1)

CLINICAL FEATURES

Risk factors
Environmental/ Precancerous lesions Genetic and familial
Genetic and familial
occupational/diet/habits
 Smoking/alcohol/obesity  H. pylori  E-cadherin gene
 Consuming red meat, infection, mutation in
smoked salmon fish, chronic gastritis diffuse cancers
cabbage, diet rich in  Pernicious  Mutation in
nitrosamines, lead anaemia APCgene for p-
 Occupational-rubber/ coal Intestinal catenin in
workers metaplasia intestinal
 Lower social status→distal  Adenomatous cancers-50%
cancers polyps more  Inactivation
  Higher social than 2 cm tumour
status→proximal cancers  Benign gastric suppressor gene
ulcer p53 in 30% cases
 Previous gastric  Loss of
surgery heterozygosity
Menetrier's in the BCL2
disease gene, an
inhibitor of
apoptosis
(intestinal type)
 Blood group A

Clinical features
Symptoms
 Asymptomatic in early gastric cancer or often in cancer of body of stomach.
 Dyspepsia (any new onset of dyspepsia over the age of 45 should be
considered to be due to adenocarcinoma until proven otherwise).
 Weight loss, anorexia, and lethargy.
 Anaemia (iron deficiency due to chronic blood loss).
 Occasionally presents as acute upper GI bleeding
 Dysphagia uncommon unless involving the proximal fundus and gastro-
oesophageal junction.
 Symptoms of Gastric outlet Obstruction(distal antral tumors)
ü Early satiety, bloating, indigestion, anorexia, nausea, vomiting,
epigastric pain, and weight loss.
ü Patients are frequently malnourished and dehydrated and have a
metabolic alkalosis, factors that increase operative
 Upper abdominal pain with vague epigastric discomfort, constant nonradiating
pain which is not related to food intake.
 Epigastric lump
 Symptoms of metastatic disease
 Occasionally carcinoma stomach can present as perforation

Signs
 Features of gastric outlet obstruction
ü Visible Gastric Peristalsis
ü Auscultopercussion test + ve
ü +ve succussion splash
  Mass in pylorus lies above the umbilicus, nodular, hard, with impaired
resonance, mobile, moves with respiration
 In case of metastasis
ü +ve Troisier's sign.
ü liver may be palpable with secondaries which are hard, nodularwith
umbilication.
ü +ve rectovesical secondaries. (Blumer shelf) on per rectal examination.
ü + ve Trousseau sign-migrating thrombophlebitis
ü Secondaries in umbilicus, as Sister Joseph's nodules
 Unusual presentations-acanthosis nigricans, Irish node in the left anterior
axillary region.

Diagnosis

 Routine blood → CBC,LFT, Urea,Creatinine,Electrolyte

 Barium meal Study
o Irregular filling defect
o Loss of rugosity
o Delayed emptying
o Dilatation of stomach in carcinoma pylorus
o Decreased stomach capacity in linitis plastica
o Margin of the lesion projects outward from the ulcer/lesion into the
gastric lumen-Carmanns meniscus sign
 Upper GI Endoscopy and biopsy from lesion
 EUS
To detect the involvement of layers of the stomach, nodal status and to define
whether tumour is early or advanced
 Ultrasound abdomen to see liver secondaries, ascites, nodes, ovaries.
 CT Scan ( Abdomen and Thorax) to look for LN Status,operability, Secondaries
 Laparoscopy to stage disease
Signs of Inoperability
Involvement of distant peritoneum, Ascites, Fixation to nonremovable
adjacent structures (Pancreas, diaphragm).
 Tumor Markers → CA 72-4 is important tumour marker to evaluate the
relapse. Other markers are CEA, CA 19-9, CA 12-5
Treatment

Preoperative Preparation
 ü Correction of anaemia, nutrition, fluid and electrolyte
ü Cardiac, respiratory and renal status assessment and optimization
ü Stomach wash using normal saline
ü Prophylactic antibiotic
ü Blood/FFP may be needed preoperatively and for surgery

Surgery
Early growth in Pylorus Lower radical gastrectomy with proximal
5 cm clearance is ( Subtotal gastrectomy),
along with removal of greater omentum,
lesser omentum,tail of pancreas (when
required)
D2 Clearance and later Billroth II
anastomosis.
Growth in the OG junction or upper part Total gastrectomy with lymph node
of the stomach Clearance
Growth in the body or linitis plastica total gastrectomy (radical) with
oesophagojejunal anastomosis

Lymph Node Clearance

D 1 Clearance  Done when nodes are N0
 It is removal of nodes along
the lesser and greater curves and
pylorus (Group I: stations 3-6)
D 2 Clearance  Done when nodes are N1
 Here node stations 1- 11 are
removed.
D 3 Clearance  Done when nodes are N2
 Nodes removed for clearance are
hepatoduodenal, nodes along
mesentery, middle colic (1-16
stations).

Recent Advance
v Endoscopic mucosa/ resection (EMR) in early gastric cancer.Tumour less than
2 cm, elevated, well-differentiated tumours without nodal disease is the ideal
selection for EM.
v Photodynamic therapy
Adjuvant Therapy
Chemotherapy Chemoradiotherapy lmmunochemotherapy
FAM regime is 5- Postoperative It is given in stage Ill
fluorouracil, adriamycin, radiotherapy (RT) with carcinoma after radical
mitomycin C chemotherapy using 5 FU gastrectomy.
Neoadjuvant and leucovorin. It starts from 5th
chemotherapy to Chemoradiation has postoperative day to the
downstage the tumour is become the standard end of 2 years
also used to make it adjuvant treatment.
operable later.

Palliative treatment

Done in case of In operable disease

 To palliate pain
 To palliate vomiting
 To improve appetite

Options
 Palliative partial gastrectomy is the best palliation
 Palliative anterior gastrojejunostomy with jejuno-jejunostomy.
 Palliative chemotherapy is used in advanced stage
 Radiotherapy and analgesia like morphine is used to relieve pain.
 Endoscopic stenting/dilatation

Gastrinoma (ZE syndrome). (2017 regular; P-1)

Introduction
Gastrinoma is MC functioning malignant pancreatic endocrine tumor.
ZES occur in two forms: Sporadic (75%) & MEN-1 association (25%)

Location
MC site is duodenum followed by Pancreas
About 70-90% of gastrinomas are located within the Passaro’s triangle

Clinical Features
 Abdominal pain
 Diarrhea
 GERD
Diagnosis
 Hypergastrinemia with increased secretion of gastric acid
 fasting serum gastrin level >100 pg/mL
 Elevated serum gastrin level with a pH <2 in the gastric aspirate.
 In Case of doust
Secretin Provocation Test: An increase of >200 pg/mL in the gastrin value after
administration of secretin is diagnostic

Treatment
 Acid secretion is controlled by PPIs
 Pharmacologic control of acid secretion with PPIs has rendered total
gastrectomy and other surgical acid-reducing procedures unnecessary
 Distal pancreatectomy: Gastrinoma involving body or tail of pancreas
 Pancreaticoduodenectomy: Gastrinoma involving headQof pancreas

Stress gastritis. (2012 regular; P-2)

It is characterized by multiple, superficial (nonulcerating) erosions that begin in the
proximal or acid-secreting portion of the stomach and progress distally

Site
Almost always seen in the fundus& rarely in distal stomach.

Pathophysiology
Impaired mucosal defense mechanisms against luminal acid such as a reduction in
blood flow, mucus, and bicarbonate secretion by mucosal cells, or a reduction in
endogenous prostaglandins

Risk factors
 ARDS
 Multiple trauma
 Major burn > 35% of BSAQ
 Oliguric renal failure
 Large transfusion requirements
  Hypotension
 Prolonged surgical procedures
 Sepsis

Clinical Features
Painless upper GI bleeding

Diagnosis:
UGIE

Treatment
Definitive fluid resuscitation with correction of any coagulation abnormalities and
treatment of the underlying sepsis
Intraluminal gastric pH should be maintained >5.0 with antisecretory agents.
Most of the superficial erosions are not actively bleeding do not require ligature
unless a blood vessel is seen at its base.