Gastric Cancer

Gastric cancer is the 3rd-most common cause of cancer-related deaths worldwide. The majority of cases are from adenocarcinoma. The modifiable risk factors include Helicobacter Helicobacter Helicobacter pylori is a gram-negative bacterium that causes gastric infection. It is the most well known and clinically significant species of Helicobacter. Transmission is believed to occur by ingestion of contaminated food or water; therefore, a higher prevalence of infection is seen in areas with poor sanitation. Helicobacter pylori infection, smoking, and nitrate-rich diets. Hereditary syndromes, pernicious anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview, and prior partial gastrectomy are among the endogenous risk factors. When symptoms such as epigastric fullness, vomiting, and weight loss occur, it is likely that the cancer is in the advanced stage. Diagnosis is confirmed with esophagogastroduodenoscopy and biopsy. Imaging studies and laparoscopy Laparoscopy Laparoscopy is surgical exploration and interventions performed through small incisions with a camera and long instruments. Laparotomy and Laparoscopy aid in determining the cancer stage. Consequently, staging Staging Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis dictates the management approach. Management consists of gastrectomy and chemoradiotherapy. Most cases are diagnosed in late stages, indicating a generally poor prognosis.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Epidemiology

  • 3rd-most common cause of cancer-related death worldwide
  • High incidence in Eastern Asia, Eastern Europe, and South America
  • Regional differences noted: ↓ incidence in the United States, but ↑ in Japan and South Korea
  • Men > women
  • Median age at the time of diagnosis: 70 years

Etiology

Endogenous risk factors:

  • Chronic atrophic gastritis Gastritis Gastritis refers to inflammation of the gastric mucosa. Gastritis may occur suddenly (acute gastritis) or slowly over time (chronic gastritis). Gastritis may be asymptomatic or with symptoms, including burning abdominal pain (which either worsens or improves with eating), dyspepsia, nausea, and vomiting. Gastritis 
  • Pernicious anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview
  • Previous partial gastrectomy (antrectomy)
  • Blood type A
  • Menetrier’s disease (extreme hypertrophy of gastric rugal folds)
  • Bile reflux
  • Genetic factors and hereditary syndromes:
    • Hereditary diffuse gastric cancer (associated with E-cadherin gene or CDH1 mutation Mutation Genetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Types of Mutations)
    • Gastric adenocarcinoma and proximal polyposis of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach (GAPPS)
    • Familial intestinal gastric cancer (FIGC)
    • Hereditary nonpolyposis colorectal cancer Colorectal cancer Colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths in the United States. Colorectal cancer is a heterogeneous disease that arises from genetic and epigenetic abnormalities, with influence from environmental factors. Colorectal Cancer ( HNPCC HNPCC Lynch syndrome, also called hereditary non-polyposis colorectal cancer (HNPCC), is the most common inherited colon cancer syndrome, and carries a significantly increased risk for endometrial cancer and other malignancies. Lynch syndrome has an autosomal dominant inheritance pattern involving pathogenic variants in one of the mismatch repair (MMR) genes or epithelial cell adhesion molecule (EpCAM). Lynch syndrome)
    • Peutz-Jeghers syndrome Peutz-Jeghers Syndrome Peutz-Jeghers syndrome (PJS) is an autosomal-dominant inherited disorder characterized by GI polyps and mucocutaneous-pigmented macules. Peutz-Jeghers syndrome is 1 of the polyposis syndromes, a group of inherited or acquired conditions characterized by the growth of polyps in the GI tract and associated with other extracolonic features. Peutz-Jeghers Syndrome
    • Familial adenomatous polyposis Familial Adenomatous Polyposis Familial adenomatous polyposis (FAP) is an autosomal dominant inherited genetic disorder that presents with numerous adenomatous polyps in the colon. Familial adenomatous polyposis is the most common of the polyposis syndromes, which is a group of inherited or acquired conditions characterized by the growth of polyps in the GI tract, associated with other extracolonic features. Familial Adenomatous Polyposis ( FAP FAP Familial adenomatous polyposis (FAP) is an autosomal dominant inherited genetic disorder that presents with numerous adenomatous polyps in the colon. Familial adenomatous polyposis is the most common of the polyposis syndromes, which is a group of inherited or acquired conditions characterized by the growth of polyps in the GI tract, associated with other extracolonic features. Familial Adenomatous Polyposis)
    • Li-Fraumeni syndrome

Exogenous risk factors:

  • Chronic Helicobacter Helicobacter Helicobacter pylori is a gram-negative bacterium that causes gastric infection. It is the most well known and clinically significant species of Helicobacter. Transmission is believed to occur by ingestion of contaminated food or water; therefore, a higher prevalence of infection is seen in areas with poor sanitation. Helicobacter pylori infection (associated with distal intestinal-type adenocarcinoma)
  • Long-term diet rich in nitrates Nitrates Nitrates are a class of medications that cause systemic vasodilation (veins > arteries) by smooth muscle relaxation. Nitrates are primarily indicated for the treatment of angina, where preferential venodilation causes pooling of blood, decreased preload, and ultimately decreased myocardial O2 demand. Nitrates (found in dried, smoked, salted, and partially decayed foods) 
  • Low vegetable consumption
  • Smoking
  • Epstein-Barr virus Epstein-Barr Virus Epstein-Barr virus (EBV) is a linear, double-stranded DNA virus belonging to the Herpesviridae family. This highly prevalent virus is mostly transmitted through contact with oropharyngeal secretions from an infected individual. The virus can infect epithelial cells and B lymphocytes, where it can undergo lytic replication or latency. Epstein-Barr Virus (EBV) infection
  • Abdominal irradiation in cancer survivors

Types of Gastric Cancer

Adenocarcinoma

  • 85% of gastric cancers
  • Main histologic types:
    • Intestinal type (70%): 
      • Tumor cells exhibit adhesion and have glandular formations.
      • More common in men and older age groups
      • Associated with ↑ incidence in lower socioeconomic classes 
      • Better prognosis
    • Diffuse type (30%): 
      • Poorly cohesive histology, lacking intercellular adhesions (includes signet-ring cell carcinoma)
      • Tumor cells with likelihood of infiltration and manifestation as stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach wall thickening instead of a mass
      • Stomach loses distensibility.
      • Equal sex distribution
      • More common in younger age groups
      • Overall, worse prognosis

Primary gastric lymphoma

  • 13% of gastric cancers
  • Stomach: most common extranodal site of lymphoma
  • Ranges from superficial mucosa-associated lymphoid tissue (MALT) to large cell lymphoma
  • MALT development is associated with H. pylori infection.

Gastrointestinal stromal tumors (GIST)

  • Stromal or mesenchymal tumors, constituting approximately 1% of primary gastric cancers
  • Found in other areas of the digestive tract, but most are in the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach

Carcinoid tumors Carcinoid tumors Carcinoid tumors are small, well-differentiated, slow-growing neuroendocrine tumors (NET). Carcinoid syndrome describes the signs and symptoms associated with unregulated vasoactive hormone production by neuroendocrine tumors. Carcinoid tumors are most commonly found in the GI and bronchopulmonary tracts. Carcinoid Tumors and Syndrome

  • Rare
  • Slow-growing neuroendocrine tumors
  • Originate from the hormone-producing (enterochromaffin) cells

Pathophysiology

Intestinal type

  • Chronic infection with H. pylori: a primary risk factor for (intestinal-type) non-cardia gastric cancer
  • Prolonged exposure to risk factor → atrophic gastritis Gastritis Gastritis refers to inflammation of the gastric mucosa. Gastritis may occur suddenly (acute gastritis) or slowly over time (chronic gastritis). Gastritis may be asymptomatic or with symptoms, including burning abdominal pain (which either worsens or improves with eating), dyspepsia, nausea, and vomiting. Gastritis → achlorhydria or hypochlorhydria → ↑ stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach pH → microbial colonization and loss of cells (which produce epidermal and transforming growth factors) needed to regenerate damaged tissue 
  • Follows a pattern of stepwise progression (Correa’s cascade): chronic gastritis Gastritis Gastritis refers to inflammation of the gastric mucosa. Gastritis may occur suddenly (acute gastritis) or slowly over time (chronic gastritis). Gastritis may be asymptomatic or with symptoms, including burning abdominal pain (which either worsens or improves with eating), dyspepsia, nausea, and vomiting. Gastritis → chronic atrophic gastritis Gastritis Gastritis refers to inflammation of the gastric mucosa. Gastritis may occur suddenly (acute gastritis) or slowly over time (chronic gastritis). Gastritis may be asymptomatic or with symptoms, including burning abdominal pain (which either worsens or improves with eating), dyspepsia, nausea, and vomiting. Gastritis → intestinal metaplasia → dysplasia (direct precursor of cancer) → adenocarcinoma

Diffuse type

  • Associated with loss-of-function mutations of CDH1 (tumor suppressor gene that encodes E-cadherin, a cell-adhesion protein) 
  • Neoplastic cells without intercellular adhesion (due to loss of expression of E-cadherin) → infiltration of neoplastic cells within the gastric wall → diffuse thickening of the gastric wall → loss of distensibility (known as linitis plastica, or “leather-bottle” appearance)

Clinical Presentation

Symptoms

  • Asymptomatic in early stages when the cancer is more curable
  • By the time symptoms start, the cancer is already advanced.
  • Initial symptoms occur with insidious onset:
    • Epigastric discomfort (postprandial fullness, steady pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain)
    • Anorexia
    • Nausea 
  • Later symptoms as disease progresses:
    • Weight loss
    • Increased nausea and early satiety (noted in linitis plastica as the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach is unable to distend)
    • Vomiting or gastric outlet obstruction (especially with pyloric tumors)
    • Dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming "stuck." Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia (especially with diffuse-type, esophagogastric and cardiac tumors)
    • Melena or hematemesis

Signs

  • Normal physical exam early in the disease 
  • Epigastric mass indicates long-standing growth.
  • Signs of metastatic gastric carcinoma:
    • Hepatomegaly or palpable liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver mass
    • Virchow’s node: palpable node in the left supraclavicular region
    • Irish node: palpable nodes in the left axillary
    • Blumer’s shelf (mass in the pouch of Douglas Pouch of Douglas A sac or recess formed by a fold of the peritoneum. Ovaries): palpable on digital rectal or vaginal examination
    • Sister Mary Joseph’s nodule: periumbilical nodule 
    • Krukenberg tumor: malignancy in the ovaries Ovaries Ovaries are the paired gonads of the female reproductive system that contain haploid gametes known as oocytes. The ovaries are located intraperitoneally in the pelvis, just posterior to the broad ligament, and are connected to the pelvic sidewall and to the uterus by ligaments. These organs function to secrete hormones (estrogen and progesterone) and to produce the female germ cells (oocytes). Ovaries representing metastasis from another site (gastrointestinal source most often)
    • Ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Ascites: can indicate peritoneal carcinomatosis

Paraneoplastic findings

  • Malignant acanthosis nigricans: rapid appearance/growth of dark and velvety patches (usually on skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin folds) 
  • Diffuse seborrheic keratoses (Leser-Trélat syndrome)
  • Dermatomyositis
  • Hypercoagulable Hypercoagulable Hypercoagulable states (also referred to as thrombophilias) are a group of hematologic diseases defined by an increased risk of clot formation (i.e., thrombosis) due to either an increase in procoagulants, a decrease in anticoagulants, or a decrease in fibrinolysis. Hypercoagulable States state
  • Membranous nephropathy

Diagnosis

Surveillance

  • No recommendations for the general population
  • High-risk patients for whom upper endoscopy may be of benefit:
    • Familial adenomatous polyposis Familial Adenomatous Polyposis Familial adenomatous polyposis (FAP) is an autosomal dominant inherited genetic disorder that presents with numerous adenomatous polyps in the colon. Familial adenomatous polyposis is the most common of the polyposis syndromes, which is a group of inherited or acquired conditions characterized by the growth of polyps in the GI tract, associated with other extracolonic features. Familial Adenomatous Polyposis
    • Gastric adenomas
    • Elderly with atrophic gastritis Gastritis Gastritis refers to inflammation of the gastric mucosa. Gastritis may occur suddenly (acute gastritis) or slowly over time (chronic gastritis). Gastritis may be asymptomatic or with symptoms, including burning abdominal pain (which either worsens or improves with eating), dyspepsia, nausea, and vomiting. Gastritis or pernicious anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview
    • Hereditary nonpolyposis colorectal cancer Colorectal cancer Colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths in the United States. Colorectal cancer is a heterogeneous disease that arises from genetic and epigenetic abnormalities, with influence from environmental factors. Colorectal Cancer 
    • History of partial gastrectomy
    • High risk immigrant ethnic population

Diagnosis

  • Esophagogastroduodenoscopy (EGD):
    • Diagnostic imaging procedure of choice
    • Evaluates gastric mucosa and lymph node involvement
    • Allows deep mucosal/ulcer biopsy (to distinguish benign from malignant ulcers)
    • Possible findings suggesting gastric cancer:
      • Friable ulcerated mass
      • Gastric ulcer with irregular or thickened margins 
      • In linitis plastica, normal mucosa is noted but with poor stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach distensibility.
  • Double-contrast barium swallow study:
    • Low sensitivity 
    • Useful in evaluating linitis plastica, which has a leather-bottle appearance
Linitis plastica

Endoscopic image of linitis plastica, where the entire stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach is invaded with cancer, leading to a leather-bottle appearance

Image: “Linitis plastica” by Samir. License: Public Domain

Staging procedures

  • Computed tomography (CT) of the chest, abdomen, and pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis:
    • Provides information on the primary tumor and the local extent of the disease
    • Evaluates areas for distant metastasis 
  • Endoscopic ultrasonography (EUS): 
    • Most reliable in evaluating depth of tumor invasion 
    • Detects regional nodal involvement and allows fine-needle aspiration of lymph node
  • 18-fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan:
    • Detection of occult metastatic lesions (especially in ≥ T2N0 disease)
    • More sensitive than CT in detecting distant metastases
  • Staging laparoscopy Laparoscopy Laparoscopy is surgical exploration and interventions performed through small incisions with a camera and long instruments. Laparotomy and Laparoscopy:
    • As peritoneal metastases can be missed by CT, laparoscopy Laparoscopy Laparoscopy is surgical exploration and interventions performed through small incisions with a camera and long instruments. Laparotomy and Laparoscopy helps determine occult peritoneal dissemination. 
    • Allows peritoneal washings and cytology
Giant polypoid tumor

(a) Upper gastric endoscopy revealing a giant polypoid-type tumor extending from the duodenum bulb to the pyloric ring
(b) An endoscopic ultrasound test suggesting tumor invasion of the muscular tunic (white arrows)

Image: “Giant polypoid tumor expressing on the pyloric ring” by Sonoda H, Kobayashi T, Endo Y, Irie S, Hirata T, Minamimura K, Mafune K, Mori M. License: CC BY 3.0

Tumor, Nodes, Metastases (TNM) Classification and Stages

Table: TNM classification for the staging Staging Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis of gastric carcinoma
T (primary tumor) N (lymph nodes affected) M (distant metastases)
TX Cannot be assessed N0 No regional lymph nodes M0 No distant metastases
T0 No evidence of tumor N1 1–2 regional nodes M1 Confirmed metastases
Tis Carcinoma in situ N2 3–6 regional nodes
T1 Invasion up to submucosa N3 7 or more regional nodes
T2 Invasion of muscularis propria
T3 Invasion of serosa
T4a Perforates serosa
T4b Adjacent structures affected
Table: Clinical Staging System for Gastric Carcinoma
StageTNMFeatures
0 TisN0M0 Node negative; limited to mucosa
1 T1-2N0M0 Node negative; invasion of submucosa up to muscularis propria
2a T1N1-3M0
T2N1-3M
Node positive; invasion of muscularis propria
2b T3N0M0
T4aN0M0
Node negative; invasion up to serosa
3 T3,N1-3,M0
T4a,N1-3, M0
Node positive; invasion up to serosa
4a T4b, any N, M0 Node positive; beyond serosa, up to adjacent structures
4b Any T, N, M1 Distant metastases
Clinical staging of gastric cancer

Clinical staging Staging Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis of gastric cancer:
Stage 0: node negative; limited to mucosa
Stage 1: node negative; invasion of submucosa and part of muscularis propria
Stage 2: node negative with invasion up to serosa or node positive with invasion up to muscularis propria
Stage 3: node positive; invasion of serosa
Stage 4: node positive; invasion up to adjacent structures with or without distant metastasis

Image by Lecturio.

Management and Prognosis

Management

  • H. pylori eradication therapy for those with positive infection
  • Clinical staging Staging Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis dictates initial therapy. 
  • Locoregional disease (stage I–III):
    • Preoperative (neoadjuvant) chemotherapy for downstaging
    • Surgery for proximal tumors: total gastrectomy and resection of adjacent lymph nodes 
    • Surgery for distal (lower ⅔) tumors: subtotal gastrectomy and resection of adjacent lymph nodes
    • Postoperative (adjuvant) combination chemotherapy ± chemoradiotherapy (depending on the stage)
  • Locally advanced unresectable or metastatic (stage IV):
    • Limited palliative gastric resection 
    • Palliative chemotherapy
    • Radiation therapy 
    • Trastuzumab if human epidermal growth factor receptor 2 (HER2)–positive tumor
    • Endoscopic stenting
  • Other: prophylactic gastrectomy considered in those with E-cadherin gene or CDH1 mutation Mutation Genetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Types of Mutations

Prognosis

  • 5-year survival of gastric adenocarcinoma is 30%.
  • 5-year survival for those who undergo curative surgical resection is > 45%.
  • Main factors determining prognosis after resection: 
    • Staging 
    • Histologic type
    • Resection margins

Postgastrectomy Complications

Small intestinal bacterial overgrowth (SIBO)

  • The normally low amount of bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology: Overview in the small intestine Small intestine The small intestine is the longest part of the GI tract, extending from the pyloric orifice of the stomach to the ileocecal junction. The small intestine is the major organ responsible for chemical digestion and absorption of nutrients. It is divided into 3 segments: the duodenum, the jejunum, and the ileum. Small Intestine increases or other pathogens have significant growth.
  • Bacterial overgrowth facilitated by decreased gastric acid secretion and blind loops
  • Clinical features: 
    • Diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, bloating
    • Malabsorption Malabsorption Malabsorption involves many disorders in which there is an inability of the gut to absorb nutrients from dietary intake, potentially including water and/or electrolytes. A closely related term, maldigestion is the inability to break down large molecules of food into their smaller constituents. Malabsorption and maldigestion can affect macronutrients (fats, proteins, and carbohydrates), micronutrients (vitamins and minerals), or both. Malabsorption and Maldigestion that leads to weight loss
    • Steatorrhea and osmotic diarrhea
  • Diagnosis: 
    • Jejunal aspirate cultures
    • Carbohydrate (lactulose) breath test 
  • Management: antibiotics and nutrient supplementation

Dumping syndrome

  • Related to motility (rapid gastric emptying)
  • Due to bypass of pyloric sphincter
  • Early dumping type:
    • Impaired pyloric sphincter leads to rapid emptying of hyperosmolar chyme.
    • Vomiting, diarrhea, abdominal cramps
    • Vasomotor symptoms (sweating, flushing, and palpitations) occur after ingestion of a meal.
  • Late dumping type: 
    • Rapid glucose absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption causes hyperinsulinemic response.
    • Postprandial hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia 
    • Tremor and faintness occurring 1 hour after the meal
  • Management: 
    • Dietary modifications (more fiber); frequent small meals that are rich in protein and fat
    • Consider octreotide; reoperation in certain cases

Gastric stasis

  • Related to motility (slow transit)
  • Due to vagal denervation, small stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach remnant, or postsurgical atony
  • Clinical features: early satiety, vomiting, abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Management: 
    • Use of prokinetic agents
    • If severe, total gastrectomy considered

Other long-term effects

  • Reduced iron absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption: anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview 
  • Reduced B12 absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption (no intrinsic factor): B12 deficiency 
  • Reduced calcium absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption: osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis 
  • Gallstones
  • Peptic ulcer Peptic ulcer Peptic ulcer disease (PUD) refers to the full-thickness ulcerations of duodenal or gastric mucosa. The ulcerations form when exposure to acid and digestive enzymes overcomes mucosal defense mechanisms. The most common etiologies include Helicobacter pylori (H. pylori) infection and prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs). Peptic Ulcer Disease
  • Partial gastrectomy is a risk for remnant cancer.

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