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Stomach cancer

Stomach cancer is a common type of cancer in Hong Kong. In 2019, there were 1 303 new cases of stomach cancer, accounting for 3.7% of new cancer cases. Its crude annual incidence rate per 100 000 Hong Kong population was 17. In 2019, a total of 696 people died from this cancer, accounting for 4.7% of all cancer deaths. The incidence rate of stomach cancer rises with age. The median age at diagnosis was 70 and 69 in male and female respectively.

The early symptoms of stomach cancer are not specific. Many patients regard these symptoms as stomach upset and take them lightly so that diagnosis of stomach cancer is often delayed. Therefore, more than half of the patients present with advanced stage in which the cancer has already spread to other tissues.

What is Stomach Cancer?

Stomach is one part of the digestive system. It secretes gastric acid to help digest and grinds large pieces of food into small ones. The food then enters the intestine by peristalsis for further digestion process.

Mutations in stomach cells lead to development into malignant tumour called stomach cancer. The etiology of stomach cancer is so far uncertain.

Who have higher chance of developing Stomach Cancer?

Many factors increase the risk of developing stomach cancer. Research shows that helicobacter pylori (a kind of bacterium which survives in the stomach and duodenum) infection may increase the chance of stomach cancer. Other risk factors include:

  • Male.
  • The older the age, the higher the chance of stomach cancer. There is a sharp rise in stomach cancer rate in people over age 50.
  • Consumption of high-salted, pickled and smoked food will increase the danger of having stomach cancer.
  • People who have stomach polyps, had gastrectomy (stomach removal surgery) or pernicious anaemia (anaemia resulted from deficiency of vitamin B).
  • Smoking.
  • People whose immediate family members have had stomach cancer are twice as likely to develop stomach cancer than others.

What are the symptoms of Stomach Cancer?

Patients with stomach cancer can have the following symptoms. However, these symptoms can be caused by other more common illnesses, such as gastritis, stomach or duodenal ulcer. If in doubt, consult a doctor as soon as possible.

  • Persistent indigestion, loss of appetite.
  • Rapid weight loss.
  • Swelling of abdomen.
  • Feeling bloated after eating.
  • Vomiting, even blood in vomitus.
  • Blood in stools, or black stools.
  • Anemia, fatigue, weakness.

Prevention

The causes of stomach cancer are still not fully understood, but there are some risk factors for stomach cancer, including:

  • Advancing age;
  • Gender: Stomach cancer is more common in men;
  • Infection with Helicobacter pylori;
  • Smoking;
  • Alcohol consumption;
  • Consuming foods preserved by salting;
  • Consuming processed meat; and
  • Being overweight or obese.

In general, adopting a healthy lifestyle through regular physical activities, maintaining a healthy body weight and waist circumference, having well balanced diet (including eat more fruits and vegetables, eat less food preserved by salting and processed meat) and avoiding smoking and alcohol consumption may prevent or lower the risk of stomach cancer.

How to investigate and make diagnosis for Stomach Cancer?

People with aforementioned symptoms should consult a doctor as soon as possible and undergo tests. Detection of stomach cancer in early stages can increase the chance of cure. Tests for stomach cancer include:

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    Abdominal ultrasound and computer tomography (CT) scan

    These examinations are mainly used to diagnose and stage stomach cancer.

What are the treatments for Stomach Cancer?

After diagnosis of stomach cancer, doctor may suggest the following treatments according to the cancer stage:

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What are the complications of Stomach Cancer and its treatments?

The common complications of stomach cancer and its treatments are as follows:

  • Gastrointestinal bleeding

    Dizziness, palpitations, black tar-looking stool, coffee ground-looking vomitus.

  • Obstruction of biliary tract

    It will cause pressure to common bile duct. The patient has symptoms of yellow eye white and skin and grey stool.

  • Obstruction of pylorus

    Pylorus is a spincter structure at the end of stomach. When it is blocked by tumour, food cannot pass to duodenum through pylorus smoothly, causing upper abdominal pain and vomiting.

  • Peritonitis

    Tumor can cause stomach perforation which can complicated by peritonitis. This is a life-treatening emergency in which the patient can present with acute abdominal pain.

  • Complications after stomach removal surgery

    There may be leakage in the anastomosis after stomach removal surgery. On the other hand, patients may have symptoms such as vomiting after meal, diarrhea, dizziness and low blood pressure. These symptoms are caused by the reaction to the food passing too quickly to small intestine after the removal of part of or the entire stomach.

  • Complications of chemotherapy

    Common side effects include weakened immunity, diarrhea, nausea, vomiting, and fatigue. Doctors will arrange regular blood tests to monitor the function of bone marrow. Doctors will also prescribe drugs to reduce the side effects of chemotherapy.

  • Complications of targeted therapy

    Targeted therapy for stomach cancer may cause diarrhea, nausea, vomiting and affect cardiac function. Doctors will prescribe drugs to reduce the side effects of targeted therapy and arrange regular cardiac assessment.

How to take care of Stomach Cancer patient?

After removal of stomach, patient needs to make some adjustments in diet:

  • Advise frequent small meals, e.g. 6 meals a day and avoid eating too much, otherwise there may be vomiting, diarrhea, dizziness and low blood pressure. Avoid any drinks during and after meals to prolong the time the food staying in the stomach to promote absorption.
  • Choose food which is easy to digest.
  • Get used to chewing food slowly.
  • Take a rest after meals to prevent indigestion.
  • Avoid anemia, be aware of the supplement of vitamin B12 (e.g. liver, meat, fish and milk). Some patients need regular injection of vitamin B12.
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Oesophagogastroduodenoscopy (OGD)

  1. Introduction

    OGD is currently the best method in examining the lumen of the upper digestive tract; by using a flexible endoscope, oesophagus, stomach and duodenum can be examined. Compared with conventional X-ray examination, OGD is more accurate in making the diagnoses. With the use of different types of accessory equipment, endoscopist can perform biopsy and deliver surgical therapies for upper gastrointestinal tract diseases. Patients suffering from peptic ulcer disease or bleeding, suspected oesophageal and gastric cancer, symptoms of indigestion, acid reflux or difficulty in swallowing should receive OGD examination.

  2. Preparation before the procedure

    • Patients need to be fasted for at least 6 hours before the procedure.
    • Dentures, spectacles and metallic objects should be removed before the procedure.
    • Patients should inform the medical staff of any major medical problems including diabetes, hypertension, valvular heart disease and pregnancy, and continue their medications as instructed.
    • Patients should also provide information concerning the current medications used especially antiplatelet and anticoagulation drugs and any allergic history.
    • Patients should avoid driving to attend the outpatient procedure and also avoid heavy drinking, smoking or use of sedative before the procedure.
    • Elderly patients and those with difficulty in walking should be accompanied by family member.
  3. The procedure

    • Prior to the examination, local anaesthetics will be sprayed to the throat of patients. A flexible endoscope with a diameter of 0.9-1.2cm will then be introduced by the endoscopist through the mouth of patients to the oesophagus, stomach and the duodenum. The internal lining of the upper gastrointestinal tract will be carefully examined.
    • During the procedure, patients are fully conscious.
    • In individual cases, intravenous sedative drugs may be given depending on the clinical conditions and the patient’s tolerability to the procedure.
    • In general, the procedure will last for 5-20 minutes, but in complex cases that require additional therapies like in the control of active bleeding, the examination may be prolonged. Patients will be carefully monitored during the procedure.
  4. After the procedure

    • As the effect of local anaesthetic will persist for about an hour, patients should remain fasted until anaesthesia has worn off. This prevents choking with food or fluid intake.
    • If intravenous sedation is used, patients should avoid operating heavy machinery, signing legal documents or driving for the rest of the day.
    • Patients should follow the instruction given by the medical staff in completing the drug treatment.
  5. Risk and complication

    • Minor discomfort including nausea, mild sore throat and distension discomfort of the stomach is common. The effect of local anaesthetics will keep the throat numb for about an hour, during which swallowing is rendered difficult. These should disappear within a day.
    • Major complications including perforation, bleeding, death, cardiopulmonary complications and infection may happen although the chances are low. The complication risks vary depending on patients’ conditions and complexities of the diagnostic and therapeutic methods used. Patients should consult the attending physicians for the detail of the endoscopic procedures. When major complications arise, emergency surgical treatment may be needed and patient death may rarely occur.
  6. Follow-up

    • Patients can contact the endoscopy unit for any discomfort after the procedure, or if the patients have any question about the examination result and drug treatment.
    • However, if serious events develop, such as passage of large amount of blood, severe abdominal pain, etc. patients should seek medical advice at the nearest Accident and Emergency Department.
  7. Remarks

    For further information please contact your doctor.

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Gastrectomy

  1. Introduction

    Surgical resection of the stomach is most commonly performed as treatment for malignancy. It is also sometimes indicated for benign pathology in the stomach. An adequate surgical resection remains the only effective treatment which offers a chance of cure or long term survival in cancer of the stomach. Furthermore, a palliative resection whenever feasible is effective in relieving symptoms such as obstruction, bleeding and perforation.

  2. Preparation before the procedure

    • Nasogastric tube and Foley's catheters are inserted with the purpose to empty the stomach and bladder fro the surgery and post-operative monitoring.
    • One to two tubal drains may be inserted into the abdominal cavity to avoid intra-abdominal collection following extensive dissection for lymphatic clearance.
  3. The procedure

    • The principles underlying a potentially curative resection of gastric cancer include:
      • Adequate tumour free margins.
      • A partial, subtotal or toal gastrectomy can be performed depending on the location of the primary tumour.
      • Resection of part of the esophagus may be performed for tumour around esophagogastric junction.
      • Safe and well-functioning reconstruction.
    • Surgical approach may include conventional open or laparoscopic techniques:
      • Conventional open gastrectomy

        It is suitable for most operable gastric cancers and generally involves a midline incision in the upper abdomen. It follows the general surgical principles for stomach cancer.

      • Laparoscopic gastrectomy

        Laparoscopic approach is regarded to be suitable for some early stage gastric cancer. It generally involves about five 1 to 4 cm incisions in the upper abdomen and the procedure is carried out laparoscopically.

    • Gastrectomy is performed under general anesthesia. Very often, epidural anesthesia or patient-control-anesthesia is added to reduce post-operative pain.
  4. After the procedure

    • Early ambulation, vigorous breathing and coughing exercise are much encouraged. These help to reduce the chance of chest infection, urinary retention as well as venous thrombosis.
    • Patients undergoing total resection of stomach are prone to anaemia due to impaired vitamin B12 absorption. Hence, supplement in form of regular intra-muscular injection is required.
    • According to individual’s tolerance, some form of dietary adjustment is likely required especially in the early post-operative period.
    • Post-operative adjuvant treatment, such as chemotheraphy and radiotherapy, may be indicated in suitable cases.
  5. Risk and complication

    • Surgical risks associated with gastrectomy occur in 1-5% and include:
      • Intra-operative / post-operative bleeding in view of the extensive field of dissection.
      • Anastomotic leakage.
      • Intra-abdominal collection and abscess.
      • Fistulation – e.g. pancreatic fistula.
      • Chest complications such infection and pneumonia, pleural fluid collection.
    • Late sequelae – bowel disturbance, dumping, mal-nutrition, anaemia etc.
    • Mortality from gastrectomy occurs in less than 1% of cases.
  6. Remarks

    For further information please contact your doctor.