1. . .

2. A CASE PRESENTATION ON CARCINOMA STOMACH
PRESENTED BY : Sabina Akter , Moriom Mamtaz , Mahmuda Naznin (GROUP C-2)

3. PARTICULARS OF THE PATIENT
NAME: Mrs. Feroza Begum AGE : 65 years SEX : FEMALE Marital status :Married HUSBAND’S NAME: Late Mr Kamal Uddin OCCUPATION: HOUSEWIFE RELIGION: ISLAM ADDRESS: Vill : Nurdakhali Thana: Mirsharai ,Ctg. DATE OF ADMISSION & TIME: at 2.45PM through emergency DATE OF EXAMINATION & TIME: at 7.00PM BED NO : 33 WARD NO: 24 Under Prof. Dr Omar Faruque Yusuf.

4. CHIEF COMPLIANTS
1.Pain in mid upper abdomen for last 3 months. 2.Vomiting for last 1.5 months 3.Weight loss for same duration

5. HISTORY OF PRESENT ILLNESS
According to patient’s statement she was relatively well 3 moths back. Then she developed pain in mid upper abdomen which was gradual in onset, deep seated, continuous dull aching in nature , radiate to whole upper abdomen, aggravated by taking food and does not relieved by medication but relieved after vomiting. Vomiting was projectile in nature, sour in taste and contained undigested food particles . She complained of loss of appetite, weakness and weight loss by 25% for same duration. She had no history of fever, jaundice , haematemesis , malena , bone pain cough ,chest pain or haemoptysis.
Her bowel and bladder habit is normal

6. SOCIO-ECONOMIC HISTORY: She belongs to middle class family.
PAST HISTORY: Patient had history of peptic ulcer disease for last 7 years and history of HTN for last7 years , no history of diabetes , bronchial asthma and any other co morbid disease
SOCIO-ECONOMIC HISTORY: She belongs to middle class family.
PERSONAL HISTORY : Patient is non smoker , non alcoholic  . She gives history of taking betel leaf for last 20 years.
FAMILY HOSTORY: No member of her 1st degree relatives suffered from such kind of disease. No heridiatary disease is transmitting through her family.
DRUG HISTORY: Patient had been taking anti ulcerant for last 7 years.
IMMUNIZATION HISTORY: Not Immunized to any specific disease
MENTRUATION HISTORY: She is a menopausal women for last 10 years
Transfusion History : None
ALLERGIC HISTORY : Not known

7. GENERAL EXAMINATION Appearance : Anxious Body built : Average
Co-operation: Co-operation
Decubitus: On lying
Nutrition: Average
Anaemia : Present[+]
Jaundice : Absent
Cyanosis: Absent
Dehydration : Present[+]
Edema : Present
Pulse : 72 beats|min
Blood pressure : 130|80 mmHg
Temperature : 99*F
Respiratory rate:18 breaths\min
Neck vein: Not engorged
Thyroid gland: Not enlarged
Peripheral lymph node: Not palpable
Hernial orifices : Intact
Others : I\V cannula in situ in the left hand with 5% DA infusion.

8. LOCAL EXMINATION Inspection: Superficial : Abdomen is soft
.Abdomen: Flat & flank full
Umbilicus: Centrally placed, inverted.
There is no visible pulsation, no visible
peristalsis, no visible swelling & no surgical scar
mark.
Respiratory movement is normal & symmetrical.
Palpation :
Superficial :
Abdomen is soft
Temperature is normal
Tenderness: Present on epigastric region.

9. On deep palpation An ill defined mass present in
epigastric region, approx 3”x 2”
in size, firm in consistency,
move with respiration, not fixed with
overlying skin and underlying structure.
Murphy’s sign: Negative
Liver : not enlarged
Spleen : not palpable
Succussion splash : not present
Fluid thrill: Absent.

10. Percussion :
Percussion note : Tympanic.
Shifting dullness: Absent.
Upper border of liver dullness-
In right 5th intercostal space.
Auscultation:
Bowel sound- Present and normal .
Abnormal bruit- Absent.

11. Digital rectal examination:
Normal peri-anal region with normal anal
tone.
No skin tag.
Rectal mucosa free.
Finger is stained with stool , not blood
tinged.
OTHER SYSTEMIC EXAMINATION : Reveals no
abnormality.

12. PROVISIONAL DIAGNOSIS
GASTRIC OUTLET OBSTRUCTION DUE TO CARCINOMA OF STOMACH .

13. DIFFERENTIAL DIAGNOSIS
1. Pyloric stenosis secondary to peptic ulcer disease
2.Carcinoma head of the pancreas
3.Ca of transverse colon

14. SALIENT FETURE
Mrs. Feroza Begum, 65years old lady hailed from Mirsharai , got admitted into CMCH with the complaints of
Pain in epigastric region for last 3 months
Vomiting for last 1.5 months
According to patient statement she was relatively well about 3 months back. Then she developed pain in epigastric region which was gradual in onset , deep seated , continuous dull aching in nature, radiated to whole abdomen , aggravated by taking food and relieved after vomiting. Vomiting was spontaneous , projectile, sour in taste, contained undigested food particles. She complained of anorexia, weakness and significant weight loss[25%] for same duration. She had no history of fever, jaundice, haematemesis, melena, bone pain or cough or chest pain . Patient had history of peptic ulcer disease for last 7 years Patient is anxious , cooperative , avarege body build , &nutrition . Patient is anaemic , not icteric , dehyadrated and edema was present in lower leg . Pulse was 72 beat\min , blood pressure 130\80 mmHg , temperature 99 *F and respiratory rate 18 breaths\min . On examination , abdomen was flat, umbillicus centrally placed, no visible scar mark , no visible peristalsis. An ill defined mass was present in epigastric region, approx 3”x 2” in size, firm in consistency, move with respiration, not fixed to overlying skin, or underlying structure. Liver and spleen are not palpable & no other organomegaly . Succussion splash was absent . Digital rectal examination shows no abnormality . Other systemic examination reveals no abnormality .

15. INVESTIGATION
For diagnosis: Endoscopy of upper GIT with possible biopsy For metastasis: USG of whole abdomen Chest X-RAY P\A VIEW Liver function test For anaesthetic fitness: CBC RBS Serum urea serum creatinine ECG serum albumin serum electrolyte.

16. . On biochemical finding, ON INVESTIGATION , our findings,
On-endoscopic finding ,
Stomach Large ulcer involving antrum & part of the body with narrowing
of pylorous.
On histo-pathological finding,
Fragments of gastric mucosa howing ulcer & inflammatory exudate on the surface & mixed with atypical epithelial cells & glands compatible with poorly differentiated adenocarcinoma.
On biochemical finding,
Na+ : 132 ml mol\L
K+ : 3.2 mlmol\L
Cl- : 93 mlmol\L
HCO3- : 23 mlmol\L
ON ROUTINE EXAMINATIPON:
Hb% : 7.5 mg\dL
ON USG examination:
Few small lymph node [ Avg o.4 cm ] are seen in the para- aortic region

17. CONFIRMATORY DIAGNOSIS
GASTRIC OUTLET OBSTRUCTION due to CARCINOMA OF STOMACH

18. PREOPERATIVE PREPARTION
Management
COUNSELLING
PREOPERATIVE PREPARTION
OPERATION

19. Electrolyte correction
PATIENT PREPARATION
Anaemia correction
Electrolyte correction
Nutrition correction

20. STOMACH PREPARATION 3 days preparation Nothing by mouth
I\V fluid: Inf. DA , Inf. DNS , Inf. Normal saline
with 2amp K+
NG tube for suction & lavage
200ml every 2hrly until clear fluid
come out.
Prophylactic antibiotics

21. OPERATION
Due to presence of distant metastasis go for PALLIATIVE GASTRO-JEJUNOSTOMY.

22. CARCINOMA OF STOMACH .

23. Introduction
Ca of stomach is a major cause of cancer mortality worldwide.
It is actually an eminently curable disease provided that is detected at an appropriate stage & treated adequately.
Early diagnosis is therefore the key to success with this disease.

24. Incidence Marked variation in worldwide per million per year Japan-70
Eastern Europe-40
UK-15
USA-10
(Some geographical areas in China incidence is double that in Japan).

25. Aetiological factors
1.Age-middle to elderly 2.Sex-more in male 3.Environmental factors- a. Diet (Excessive salt intake , smoked food, deficiency of antioxidant) b . Low socio-economic condition c . Cigarette smoking 4.Host factors- Gastric polyps , gastric atrophy , chronic gastritis , achlorohydria, pernicious anaemia , duodeno gastric reflex , intestinal metaplasia. 5.Infective- H. pylori infection 6.Genetic factors- blood group-A Family H/O gastric cancer Hereditary Non polyposis colon cancer syndrome

26. Site
The proximal site of stomach is now the most common site for gastric carcinoma(60%) Upper oesophagus-2% Mid oesophagus-6% Lower oesophagus-22% Gastro oesophageal junction-18% Cardia-17% Body-15% Antrum-13% Pylorus-7%

27. Classification
Japanese classification (Early gastric cancer) 1.Protruded 2.Superficial -Depressed -Elevated -Flat 3.Excavated

28. ,,

29. Borrmann Classification (Advanced gastric Ca)
Type1:Polypoid/fungating
Type2:Ulcerated with elevated margin
Type3:Ulcerated with infiltration
Type4:Diffusely infiltrative

30. Pathogenesis

31. Clinical features Symptom
1.Early case-
New dyspepsia over 40 years
Vague post prandial abdominal heaviness
Anorexia
Malaise
2.Advanced case-
Early satiety
Bloating
Abdominal distension
Constant epigastric pain
Lump in epigastric region
Vomiting
Loss of appetite
Wt loss
Haematemesis
Malena
Features of metastasis

32. SIGN General examination Local examination Anaemia , jaundice, Wasting
Dehydration,
Enlarged supraclavicular lymph node (Virchow’s gland)
Local examination
Abdominal distension
Visible peristalsis(if obstruction)
Epigastric lump ( Irregular, tender ,hard )
Enlarged liver(if secondary deposit)
Succussion splash-Positive (If GOO)
Sister Joseph’s nodule
Trousseaus sign

33. Spread of Ca of Stomach Usually 4 ways -Direct spread
-Lymphatic spread
-Blood borne metastases
-Transperitoneal spread
Krukenberg’s tumours
Sister Joseph’s nodule

34. Staging TNM Staging T1- Involves lamina propria
T2-involves muscularis mucosa
T3-Involves serosa
T4-Involves adjacent organs
N1-Involves 1-6 regional lymph node
N2-Involves 7-15 regional lymph node
N3-Involves >15 nodes
M0-No distant metastasis
M1-Distant metastasis

35. .... Clinical Staging Stage 1 : Involvement of mucosa or submucosa.
Stage 2 : Involvement of muscularis layer
Stage 3: Involvement of lymph node
Stage 4 : Involvement of distal lymph
node or adjacent organ.

36. Investigation * For diagnosis *For metastasis *For G/A fitness
Endoscopy of upper GIT with possible biopsy
If required Barium meal X-ray of stomach and duodenum
*For metastasis
USG of whole abdomen
Chest X-ray
LFT
CT scan
Bone scan
*For G/A fitness
CBC
Urine R/M/E
Random blood glucose
Serum creatinine
Chest X-ray P/A view
ECG

37. Figure:Endoscopic findings of Ca -stomach.
Figure:Endoscopic findings of Ca -stomach

38. .
FIGURE : Barium meal X-ray of stomach &
duodenum

39. FIGURE : Barium meal X-ray of stomach &
duodenum

40. Management A. General management 1.Correction of anaemia -by blood
transfusion
2.Correction of dehydration& electrolyte
imbalance-by I/V fluid
3.Preparation of stomach by NBM & gastric
lavage
4.Correction of nutrition status by
-Parenteral nutrition
-Vit. supplementation

41. B.Surgical management CURATIVE SURGERY
1-Lower subtotal gastrectomy – If Ca of lower third of stomach
2-Total gastrectomy with Roux en-y reconstruction-When growth involve proximal1/3rd or middle1/3rd of stomach
PALIATIVE SURGERY
Gastro-jejunostomy
Palliative stenting or intubation(feeding jejunostomy)

42. Figure: Roux-en-Y Gastric bypass

43. FIGURE : Subtotal gastrectomy

44. FIGURE : Total gastrectomy

45. OTHER MODALITIES CHEMO THERAPY Commonly used chemotherapeutic
agents are ECF ( Epirobucin , Cisplatin ,
5-FU)
RADIOTHERAPY :
Has a role in palliative treatment of
painful bony metastasis.

46. SIGNS OF INOPERABILITY
Haematogenous metastasis or distant
metastasis
Fixation to pancreas or post abdominal
or involvement of the mesentary
especially the origin of the superior
mesenteric vessel.
Gross local involvement of lymph node
-N4 Nodal disease or
-Disease beyond N4 node
Involvement of distant peritoneum with
-Peritoneal seedling &
-Huge ascites

47. Post-operative complication of Ca-stomach
1.Small stomach syndrome
2.EarlyDumping
3.Late Dumping
4.Bile vomiting.
5.Nutritional deficiency
6.Anastomotic leakage
7.Secondary Haemorrhage

49. Prognostic factors of Ca-stomach
5 years survival
Early gastric cancer-90%
Stage %
Stage %
Stage %
Stage %

50. THANK YOU .