Carcinoma of the stomach, [s8]fairly common

A patient with carcinoma of his stomach is likely to be a male over 40 (male to female ratio 3:1) who presents with: (1) Dyspeptic symptoms; unfortunately these are so common that the selection of cases for further investigation is difficult. Initially, a patient with carcinoma of his stomach only has vague upper epigastric discomfort with meals, or a feeling of fullness. These non-specific symptoms may last for months, before he presents with anorexia, nausea, and increasingly severe dyspepsia. His pain lacks the periodicity of peptic ulcer pain, and is not relieved by food. (2) Vague ill-health, anaemia, and weight loss. (3) Vomiting ''coffee grounds' (altered blood), or passing melaena stools. (4) Vomiting after food; a pyloric carcinoma causes protracted vomiting, like that of pyloric stenosis due to a duodenal ulcer (11.6). (5) An upper abdominal mass, due either to the carcinoma itself, or to secondaries in his liver. (6) Jaundice, usually due to malignant nodes in his porta hepatis. (7) Ascites as the result of peritoneal deposits. (8) Other symptoms of secondary spread.

Carcinoma of the stomach may take the form of: (1) a cauliflower type of growth; (2) a malignant ulcer with raised, irregular everted edges, especially in the distal third of the lesser curve; (3) diffuse infiltration, either in its antrum, causing pyloric stenosis, or more diffusely (''leather bottle stomach'). Lymphatic involvement, and spread to the liver, occur early.

In the developing world, a patient usually presents too late for any hope of a cure; and even if a carcinoma can be resected, he is unlikely to live 5 years. In the UK, 80% of tumours are resectable, but only 5% of patients live 5 years. The exception is Japan, where the disease is so common that diagnosis is sufficiently prompt for results to be better. Radiotherapy and chemotherapy are useless.

You will not be able to do a partial, or a total gastrectomy, so try to: (1) Make the diagnosis as best you can. (2) Select and refer any resectable and potentially curable cases. These are mostly those with a small lesion seen with a barium meal. (2) Do a palliative gastrojejunostomy, if his pylorus is obstructed. This will make his last days a little more bearable, stop him vomiting, and improve his nutrition temporarily. (3) As always, palliate and comfort him as he dies (33.1).

GASTRIC CARCINOMA EXAMINATION. Look and feel for: (1) An enlarged hard supraclavicular (Virchow's) node. (2) A firm, or hard, slightly mobile, irregular epigastric mass, separate from the patient's liver. (3) An enlarged and often irregular firm to hard liver. (4) Signs that his stomach is not emptying normally: visible peristalsis, a tympanitic epigastric swelling, and a succussion splash. (5) Signs of advanced disease[md]cachexia, jaundice, and ascites. (6) Deposits in his rectovesical pouch[md]feel for a firm, fixed ''rectal shelf'.

SPECIAL TESTS. Test his stools for occult blood. If he has a firm enlarged accessible node, especially in his supraclavicular fossa, biopsy it.

X-RAYS. If possible, do a barium meal. By the time you see him, he will probably have a filling defect, or an ulcer, which you can see quite easily on screening. Inhibited peristalsis suggests a tumour.

A malignant lesion has a 65% chance of being in his antrum, a 30% chance of being in the body of his stomach, and only a 5% chance of being in his fundus.

THE DIFFERENTIAL DIAGNOSIS is mainly that of ''dyspepsia'. It includes gallstones (13.7), hepatoma (32.26), and chronic pancreatitis (13.9).

Suggesting peptic ulceration[md]a long history ([mt]2years), periodic rather than constant pain.

Suggesting non-ulcer dyspepsia[md]diffuse tenderness, no mass, less weight loss, and a variable appetite.

MANAGEMENT. If you think his tumour might be operable, consider refering him. Before sending him on a long journey, remember that: (1) although an expert might do a total or partial gastrectomy, which would be better palliation, (2) it would have a higher mortality rate, and (3) his long-term prognosis is poor, and even an expert cannot do much more for him than you can.

If the diagnosis is difficult, refer him. Or, if this is impossible, consider doing a diagnostic laparotomy. But before you do this: (1) he must understand why you are doing it, and that it may not be curative, and (2) you must be able to do a vagotomy (11-4, 11.7) if you find a benign lesion.

If he has signs of progressive pyloric obstruction, causing daily vomiting, with no signs of advanced disease (except perhaps metastatic cervical nodes), do a gastrojejunostomy as in in Section 11.7. Choose a part of his stomach wall near his greater curvature, at least 4 cm proximal to the mass. Make the stoma well away from the tumour, and make it big (at least 5 cm), in the hope that it will stay open until he dies. Make it on the anterior or posterior aspect of his stomach, preferably posterior and retrocolic, because it will empty his stomach better.

If he cannot swallow because of obstruction at his cardia, do nothing. Don't try to insert a Celestin tube, as for carcinoma of the oesophagus (32.25), because it will be difficult to keep in place.

Fig. 32-13 HBsAg AND HEPATOMA. A, the geographical distribution of the hepatitis B virus, based on the incidence of HBsAg in blood samples. B, a patient from New Guinea with hepatoma. A, after Szmuness.