50 terms

Gastric Cancer/Zollinger-Ellison Syndrome

Iggy ch 58
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what is zollinger-ellison syndrome
a rare disease manifested by upper GI ulceration, increased gastric acid secretion and one or more duodenal or pancreatic tumors called a gastrinoma
what fraction of tumors in zollinger-ellison syndrome are malignant
2/3
curative treatment for zollinger-ellison syndrome tumors
complete surgical resection
metastasis occur mainly where in zollinger-ellison syndrome
liver, regional lymph nodes
causes of ZES
gastrin-secreting tumors that stimulate the acid-secreting cells of the stomach to maximal activity
symptoms of ZES
steatorrhea (fatty poop)
diarrhea
poor response to trad. ulcer therapy
steatorrhea results from
inactivated of pancreatic lipase secondary to the large concentrations of acid and decreased amounts of bile acids
most commonly found hormone in gastrinomas
adrenocorticotropic hormone (ACTH)
how is ZES usually diagnosed
radioimmunoassay studies reveal increased serum gastrin levels in conjunction with clinical features of the disease
what is a radical pancreaticoduodenectomy (Whipple procedure)
removal of the proximal head of pancreas, duodenum, a portion of the jejunum, the stomach (partial or total gastrectomy), and gallbladder, with anastomosis of the pancreatic duct (pancreaticojejunostomy), the common bile duct (choledochojejunostmy), and the stomach (gastrojejunostomy) to the jejunum. the surgeon may also remove the spleen (splenectomy)
most cancer of the stomach are
adenocarcinomas
type of cancer that develops int he mucosal cells that form the inner-most lining of any portion or all of the stomach
adenocarcinoma
precancerous conditions of the stomach
atrophic gastritis
intestinal metaplasia
how does gastric cancer spread?
direct extension through the gastric wall into regional lymphatics which carry tumor deposits to lymph nodes; direct invasion and adherence to adjacent organs:
-liver
-pancreas
-transverse colon
inadequate acid secretion creates alkaline environments for bacterial growth; this infection is called
mucosa-associated lymphoid tissue (MALT) lymphoma which starts in the stomach
most common mode of metastasis for gastric cancer
via portal vein to the liver
via systemic circulation to the lungs and bones
largest risk factor for gastric cancer
H. pylori infection because it carries the cytotoxin-associated antigen A (CagA) gene
pts with these conditions are 2-3x's more likely to develop gastric cancer
-pernicious anemia
-gastric polyps
-chronic atrophic gastritis
-achlorhydria
the absence of secretion of HCl
achlorhydria
dietary risk factors for gastric cancer
-smoked/pickled foods
-processed foods (nitrates)
-salt added to foods
-low in fruits and vegetables
pts have an increased risk of gastric cancer in the cardia
pts with GERD/barrett's esophagus
ethnic groups with highest risk of gastric cancer in US
asian/pacific
american indians/alaskan natives
blacks
most common symptoms of gastric cancer
indigestion
abdominal discomfort
early sign of gastric cancer that occurs as tumor grows
epigastric/back pain
advanced gastric cancer symptoms
-progressive weight loss
-n/v
-weakness/fatigue
-anemia
physical assessment findings indicative of gastric cancer
-hepatomegaly
-palpable epigastric mass
hard, enlarged lymph nodes in left supraclavicular chain, left axilla, or umbilicus
-weight loss
-anemia
-fatigue
-pain
-change in bowel habits
-change in appetite
passes on the right side suggest
metastasis in the perigastric lymph nodes or liver
lab values indicative of gastric cancer
-low Hct
-low Hgb
-stool + for occult blood
-hypoalbuminemia
-abnormal bilirubin
-abnormal alkaline phosphatase
-elevated carcinoembryonic antigen (CEA)
how is gastric cancer definitively diagnosed?
EGD with biopsy
preferred method for treating gastric cancer
surgical resection to remove the tumor
*gastric organs are sensitive to radiation so they can only endure so much
special preoperative care for pts undergoing gastrectomy
-NG tube in place a few days prior
-TPN/enteral nutrition
when would the surgeon need to take out the spleen, omentum, and other relevant lymph nodes
when the tumor is located in the mid-portion or distal portion of the stomach
when is a total gastrectomy necessary?
when the tumor growth is in the proximal (upper) third of the stomach
total gastrectomy
surgeon removes entire stomach with lymph nodes and omentum; the surgeon suture the esophagus to the duodenum or jejunum to reestablish continuity of the GI tract
post-op problem manifested by epigastric pain, feelings of fullness, hiccups, tachycardia, hypotension
decreased patency caused by clogged NG tube results in acute gastric dilation
early manifestations of dumping syndrome
*30 mins after eating
-vertigo
-tachycardia
-syncope
-sweating
-pallor
-palpitations
-desire to lie down
late manifestations of dumping syndrome
90m-3h after eating caused by excessive release of insulin following rapid rise in blood glucose level resulting from the rapid entry of high-carb food into the jejunum
-dizziness
-light-headedness
-palpitations
-diaphoresis
-confusion
2 drugs that help avoid dumping syndrome
acarbose
octreotide (Sandostatin)
how does acarbose help with dumping syndrome
-decreases carbohydrate absorption
how does octreotide help with dumping syndrome
decreases gastric and intestinal hormone secretion and slows stomach and intestinal transit time
a complication of gastric surgery in which the pylorus is bypassed or removed
bile reflux gastropathy/ alkaline reflux gastropathy
symptoms of alkaline reflux gastropathy
early satiety
abdominal discomfort
vomiting
mechanical causes of delayed gastric emptying after gastric surgery
edema at anastomosis (surgical connection areas)
adhesions blocking the distal loop
metabolic causes of delayed gastric emptying after gastric surgery
hypokalemia
hypoproteinemia
hyponatremia
post-op complication when pancreatic and biliary secretions fill the intestinal loop which becomes distended causing obstruction after radical surgery
afferent loop syndrome
treatment of afferent loop syndrome
surgical correction of incomplete loop obstruction
teaching for afferent loop syndrome
pt reports bloating/pain 20-60 mins after eating followed by n/v
nutritional deficiencies likely to occur after complete removal of stomach
-iron
-folic acid
-vitamin B12
-impaired calcium metabolism
-vitamin D
what should you assess for to see if a pt has pernicious anemia after total gastrectomy
development of atrophic glossitis
-shiny/smooth/beefy tongue
advise pts on how to avoid dumping syndrome
-6 small meals/day
-diet high in protein and fat
-relatively low carb content
-low roughage
-no milk/sweets or sugars
-liquid between meals only