1 Case Study: Gastric Carcinoma

OBJECTIVES

General:This case presentation aims to identify and determine the

general health problems and needs of the patient with an admitting diagnosis of Gastric Carcinoma. This study also intends to help promote health and medical understanding of such condition through the application of the nursing skills.

Specific: To enhance knowledge and acquire more information about

Gastric Carcinoma To give an idea of how to render proper nursing care for

clients with this condition thus it can be applied for future exposures of students

To gather the needed data that can help to understand how and why the disease occurs

To identify laboratory and diagnostic studies used in Gastric carcinoma

To enumerate the clinical manifestations of the disease so as to provide prompt intervention of its occurrence.

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ACKNOWLEDGEMENT

First and foremost, I would like to express my sincerest gratitude to our Almighty God for giving me the ability and chance to finish this study and for guiding me in my everyday life and activities.

I also wish to express my deepest gratitude to my family for providing me everything I need and for their untiring support.

I also thank my friends for their constant encouragement.

And to the patient and her relatives, I want to extend my gratitude for their cooperation and for giving me the informations I need to finish this requirement.

It is also my pleasure to thank the Dean of College of Nursing, Dean May Veridiano for being always considerate and approachable and for establishing a good quality of education in our department. And to all our instructors/faculty members,I thank them fortheir guidance and all the knowledge, discipline, and lessons they have shared to us.

Finally, I thank my most beloved teachers and those special people who made me feel that they believe in me more than I do to myself.

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INTRODUCTION:Background of the

Disease

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Gastric Carcinoma

Gastric carcinoma is the most common cancer in the world after lung and

is a major cause of mortality and morbidity. Though a marked reduction has been

observed in the incidence of gastric carcinoma in North America and Western

Europe in the last 50 years, 5-year survival rates are less than 20%, as most

patients present late and are unsuitable for curative, radical surgery.

Gastric cancer can develop in any part of the stomach and may spread

throughout the stomach and to other organs; particularly the esophagus, lungs,

lymph nodes, and the liver. Stomach cancer causes about 800,000 deaths

worldwide per year.

Types:There are several Hystological types of Gastric Cancer of which

adenocarcinoma is by far the most frequent. Sarcomas and Lymphomas can also occur.

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Risk Factors:

Risk factors for gastric lymphoma include the following:

Helicobacter pylori

Long-term immunosuppressant drug therapy HIV infection aged between 50 and 59 Blood Group A

Clinical Manifestations:

Stomach cancer is often asymptomatic or causes only nonspecific symptoms in its early stages. By the time symptoms occur, the cancer has generally metastasized to other parts of the body, one of the main reasons for its poor prognosis. Stomach cancer can cause the following signs and symptoms:

Early Indigestion or a burning sensation (heartburn) Loss of appetite, especially for meat

Late Abdominal pain or discomfort in the upper abdomen Nausea and vomiting Diarrhea or constipation Bloating of the stomach after meals Weight loss Weakness and fatigue Bleeding (vomiting blood or having blood in the stool) which will appear as black.

This can lead to anemia. Dysphagia; this feature suggests a tumor in the cardia or extension of the gastric

tumor in to the esophagus.

These can be symptoms of other problems such as a stomach virus, gastric ulcer or tropical sprue and diagnosis should be done by a gastroenterologist or an oncologist.

Specific signs and symptoms for gastric lymphoma

Epigastric pain

early satiety

fatigue

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weight loss

Nausea and Vomiting

Anorexia

Weakness

Dysphagia

Staging

If cancer cells are found in the tissue sample, the next step is to stage, or find out the extent of the disease. Various tests determine whether the cancer has spread and, if so, what parts of the body are affected. Because stomach cancer can spread to the liver, the pancreas, and other organs near the stomach as well as to the lungs, the doctor may order a CT scan, a PET scan, an endoscopic ultrasound exam, or other tests to check these areas. Blood tests for tumor markers, such as carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) may be ordered, as their levels correlate to extent of metastasis, especially to the liver, and the cure rate.

Staging may not be complete until after surgery. The surgeon removes nearby lymph nodes and possibly samples of tissue from other areas in the abdomen for examination by a pathologist.

TNM staging is used T stage - Extent of penetration through the gastric wall

o Tis - Carcinoma in situ, intraepithelial tumoro T1 - Tumor extension to submucosao T2 - Tumor extension to the muscularis propria or subserosao T3 - Tumor penetration of the serosao T4 - Tumor invasion of the adjacent organs

N stage - Number and site of draining lymph nodes involved (see also N staging in the CT Scan, Findings section, below)

o N0 - No lymph nodes involvedo N1 - Metastases in 1-6 regional lymph nodeso N2 - Metastases in 7-15 regional lymph nodeso N3 - Metastases in >15 regional lymph nodes

M stage - Presence of metastaseso M0 - No distant metastaseso M1 - Distant metastases

Preferred Examination

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Begin the evaluation with history taking and physical examination. Perform blood tests, including a full blood count determination and liver function

tests. Inspect the stool, and test for occult blood. Perform either fiberoptic endoscopy or a double-contrast study (barium and gas)

of the upper GI tract.o Endoscopy has become the diagnostic procedure of choice for patients

with suspected gastric carcinoma. Biopsy samples obtained during endoscopy enable histologic diagnosis. However, endoscopy is more invasive and more costly than a double-contrast study.

o Double-contrast examinations of the upper GI tract remain a useful alternative to endoscopy and have similar sensitivity in the detection of gastric cancer.

CT, MRI, and endoscopic ultrasonography (EUS) are used in staging but not usually in the primary detection of gastric cancers (see the CT Scan, MRI, and Ultrasound sections).

Diagnosis:To find the cause of symptoms, the doctor asks about the patient's medical

history, does a physical exam, and may order laboratory studies. The patient may also have one or all of the following exams:

Gastroscopic exam is the diagnostic method of choice. This involves insertion of a fiberoptic camera into the stomach to visualize it.

Upper GI series (may be called barium roentgenogram) Computed tomography or CT scanning of the abdomen may reveal gastric

cancer, but is more useful to determine invasion into adjacent tissues, or the presence of spread to local lymph nodes.

Abnormal tissue seen in a gastroscope examination will be biopsied by the surgeon or gastroenterologist. This tissue is then sent to a pathologist for histological examination under a microscope to check for the presence of cancerous cells. A biopsy, with subsequent histological analysis, is the only sure way to confirm the presence of cancer cells.

Various gastroscopic modalities have been developed to increased yield of detect mucosa with a dye that accentuates the cell structure and can identify areas of dysplasia. Endocytoscopy involves ultra-high magnification to visualize cellular structure to better determine areas of dysplasia. Other gastroscopic modalities such as optical coherence tomography are also being tested investigationally for similar applications.

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A number of cutaneous conditions are associated with gastric cancer. A condition of darkened hyperplasia of the skin, frequently of the axilla and groin, known as acanthosis nigricans, is associated with intra-abdominal cancers such as gastric cancer. Other cutaneous manifestations of gastric cancer include tripe palms (a similar darkening hyperplasia of the skin of the palms) and the sign of Leser-Trelat, which is the rapid development of skin lesions known as seborrheic keratoses.

Possible Complications Fluid buildup in the belly area (ascites) Gastrointestinal bleeding Spread of cancer to other organs or tissues Weight loss

Outlook/Prognosis

The outlook varies widely. Tumors in the lower stomach are more often cured than those in the higher area -- gastric cardia or gastroesophageal junction. The depth to which the tumor invades the stomach wall and whether lymph nodes are involved influence the chances of cure.

In circumstances in which the tumor has spread outside of the stomach, cure is not possible and treatment is directed toward improvement of symptoms.

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DEFINITION OF TERMS

Dysphagia – difficulty in swallowing Sprue - a chronic form of malabsorption syndrome, occurring in both

tropical and nontropical forms.  Carcinoembryonic Antigen - a glycoprotein found in serum, urine,

etc. that is associated with various types of tumors: monitoring its levels is useful in treating cancer patients.

Acanthosis nigricans- A skin condition characterized by dark thickened velvety patches, especially in the folds of skin in the axilla (armpit), groin and back of the neck.

Leser-Trelat Sign – sudden appearance and rapid increase in number size of seborrhoeic keratoses withpruritus; associated with internal malignancy.

Seborrheic Keratosis – A superficial, benign, verrucose lesion consisting of proliferating epidermal cells enclosing horn cysts, usually appearing on the face, trunk, or extremities in adulthood.

H. pylori - the type species of genus Heliobacter; produces urease and is associated with several gastroduodenal diseases (including gastritis and gastric ulcers and duodenal ulcers and other peptic ulcers)

Intraperitoneal Hyperthermic Chemotherapy – Oncology The administration of heated chemotherapeutics in solution circulated in the peritoneal cavity.

Metastasis – Transmission of pathogenic microorganisms or cancerous cells from an original site to one or more sites elsewhere in the body, usually by way of the blood vessels or lymphatics.

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Ascites – is excess fluid in the space between the tissues lining the abdomen and abdominal organs (the peritoneal cavity)

Risk Factors – anything that increases a person’s chance of developing a disease

CHOP is the acronym for a chemotherapy regimen used in the treatment of non-Hodgkin lymphoma

Mutation – occurs when a DNA gene is damaged or changed in such a way as to alter the genetic message carried by that gene.

Personal Background of the

Patient

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PERSONAL DATAName: Patient X

Address: Masin Norte Candelaria, Quezon

Occupation: none

Religion: Iglesia ni Cristo

Nationality: Filipino

DEMOGRAPHIC DATADate of Birth: May 6, 1954

Place of Birth: Candelaria, Quezon

Age: 55 years old

Gender: Female

Civil Status: Married

PATIENT PROFILEDate Admitted: February 28, 2010

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3:00 pm

Attending Physician: Dr. Leonardo Holguin

Room: Female Surgical Ward 3

Hospital Record No: A-03317

ER No: E-05380

HOME ENVIRONMENT

Physical Environment: Living with her husband and 2 children

SLEEP AND REST PATTERN

Usual Sleep Pattern: Usually sleeps at 9 o’clock in the evening and

awakes at 5 o’clock in the morning. But during

hospitalization, she frequently sleep even on

daytime.

Relaxation Techniques: Sleeping and watching television are his

relaxation technique.

ELIMINATION PATTERN

Urinary: He urinates 3-4 times a day.(before

hospitalization)

With catheter(during hospitalization)

Bowel: He defecates three to four times week.(before

hospitalization)

With foley catheter,jejunostomy(during

hospitalization)

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PAST HEALTH HISTORY

Past Medical History

She has no history of previous confinement, surgery or another

chronic illness.

Medications

Paracetamol (Biogesic)

Robitusin

Mefenamic Acid

Allergies

No known allergies to food and drugs

Family History

Hypertension(Father)

HISTORY OF PRESENT ILLNESS

Reason for seeking medical care: Loss of AppetiteWeight Loss

Six months prior to admission, the patient noticed difficulty of swallowing solid foods. And she had a significant weight loss. And two weeks prior to admission, she experienced early satiety and fullness which was relieved by vomiting. Her condition then progressed to recognizable vomiting of undigested food after meals especially with solids. Since then, she experienced anorexia because of progressing difficulty of breathing. No symptoms of upper gastrointestinal bleeding. She could tolerate fluid and small amount of soft diet. Upon admission, she had been experiencing burning epigastric pain. Passing urine and bowel opening were normal.

NPO With D5NSS

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PHYSICAL EXAMINATION

Vital SignsUpon Admission Latest

Temperature 36.5°C 36.5°CPulse 90beats/min 76beats/minRespiration 25breaths/min 23breaths/minBlood Pressure 110/90mmHg 110/80mmHg

HEADSkull and Face

Rounded, normocephalic and symmetrical Uniform consistency; absence of nodules or masses Symmetric facial movements No tenderness

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Can move facial muscles at will

SCALP Dry Free from lice and nits No tenderness nor masses Lighter in color than the complexion

SKIN The skin color is pale No skin abrasions or lesions No edema present Dry skin Temperature is within normal range

HAIR Evenly distributed hair Black Variable amount of body hair

NAILS Convex curvature Smooth in texture Pale With capillary refill of 1-2 seconds

Eyes,Eyebrows and Eyelashes Eyebrows symmetrically aligned Equally distributed eyelashes Skin intact ; no discharges Sclera appears white; capillaries are evident Conjunctiva appears shiny, smooth and pink No edema or tenderness present over lacrimal gland

Conjunctiva Pale moist Transparent, shiny and smooth cornea Pupils is black in color, equal in size and reactive to light

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Ears Auricle symmetrical, aligned with outer canthus of the eyes Mobile, firm and not tender,; pinna recoils after it is folded Normal voice tones audible

Nose and Sinuses

External nose is symmetric and straight Clear-watery discharge and flaring of the nares Uniform in color No tenderness or lesions when palpated Airway is patent (air moves freely as the client breathes through

the nares Nasal septum intact and in midline

Mouth and Oropharynx

Outer lips is pale and dry Tongue in central position, pink in color; with raised papillae;

moves freely Dysphagia

NECK Neck muscles equal in size, head is centered Coordinated, smooth movements without discomfort With palpable lymph nodes

THORAX AND LUNGS Chest symmetric Skin intact; uniform temperature Chest wall intact; no tenderness, no masses Clear breath sounds Not in respiratory distress

ABDOMEN Uniform in color With intact dressing on postoperative site With foley catheter/jejunostomy

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MUSCULOSKELETAL SYTEM Equal in size on both sides of body No contractures; no tremors Coordinated movements Malaise/weakness Thin extremities Decreased Activity Tolerance

EXTREMITIES No edema Symmetric

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Laboratory Examinations

CT ScanCase no: 10-0047Abdomen: flat,soft

(+) palpable mass 5x5mm epigastric area(-)edema

Report:Multiple axial tomographic sections of the abdomen without contrasts were

obtained. CT images show a circumferential diffuse thickening of the stomach wall with a narrowed gastric lumen. The wall measures 20mm in diameter.

The liver, pancreas and spleen are normal in size and homogeneity.No focal masses, calcifications or lymphadenopathies noted.The kidneys are normal in size, position and configuration with mild dilatation of

the right renal pelvis.The rest of the soft tissue vascular and osseous structures are normal.

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Impression:Thickened Gastric WallPrimary consideration is Gastric LymphomaSuggest Endoscopy

RadiologySuspicious infiltrates in right upper lung fields, normal heart shadow

Impression:Suggest Lordotic View

UltrasoundImpression:

Epigastric mass, (?)Etiology r/o right renal pathology

Blood Chemistry

Result Normal values InterpretationRBS 148 70-110mg/dl Increased: hyperglycemia

PPBS 131 <140 NormalCreatinine 0.5 0.5-1.7 Within normal range

Sodium 142.3 135-148mol/L Within normal rangePotassium 3.31 3.5-5.3mmol/L Decreased:

hyperparathyroidism,vit.D deficiency,GI losses

MiscellaneousProthrombin Time

Result Normal values InterpretationPt’s PT 14 secs 10-14 Within normal range

INR 1.2 0.8-1.3 Within normal range%Activity 72.3% 70-100% Within normal range

Urinalysis

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Result Normal values InterpretationColor Dark yellow Yellow Concentrated,sometimes due to

some drugsTransparency Turbid Clear Semen, mucus, and lipid may cause

turbidity.Increased numbers of cells, crystals, casts, or organisms can

increase the turbidity of urine in disease conditions.

Reaction 6.0 4.8-7.8 NormalSp.Gravity 1.030 1.015-1.025 Increased:dehydrationAlbumin Trace (-) may result from excessive muscular

exertion, convulsions, or excess protein ingestion,kidney disease

Sugar (-) (-) NormalPus cells 1-3 0-2/hpf Increased: sign of an infection or

inflammation in the kidneys, bladder or another area

RBC 1-3 0-1/hpf Increased: glomerular damage, tumors which erode the urinary tract

anywhere along its length, kidney trauma, urinary tract stones, renal

infarcts, acute tubular necrosis, upper and lower urinary tract infections, nephrotoxins, and physical stress

Epith cells Few +,few NormalMucus threads Plenty +,few mucosal surface irritations

Amorphous Urates

few few Normal

Hematology

Result Normal values InterpretationWBC 5.2 5-10x109/L Within normal range

Neutrophils 69 55-65 Increased: acute infections, trauma or surgery, leukemia,

malignant disease, necrosisLymphocytes 28 25-35 Within normal rangeEosinophils 01 1-5 Within normal rangeMonocytes 02 1-6 Within normal range

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HgB 11.5 M 13.5-18.0g/dl

F 12.0-16.0g/dl

Decreased: various anemias, pregnancy,severe or prolonged hemorrhage, and with excessive fluid intake

Hct 0.37 M 0.40-0.48g/dl

F 0.37-0.45g/dl

Within normal range

Platelet adequate 150-400x109/L NormalBlood type A positive ---------

OthersResult Normal values Interpretation

MCV 65.6 80.0-99.9fi Decreased: RBCs are smaller than normal

(microcytic) as is seen in iron deficiency

anemia or thalassemiasMCH 20.3 27.0-31.0pg Decreased: microcytic red

cellsMCHC 30.9 33.0-37.0g/dl Decreased: (hypochromia)

are seen in conditions where the hemoglobin is

abnormally diluted inside the red cells, such as in iron

deficiency anemia and in thalassemia

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Anatomy and Physiology

Digestive System

The organs of digestive system can be separated into two main groups: those

forming the alimentary canal, and the accessory digestive organs. The alimentary

canal performs the whole menu of digestive functions while the accessory organs assist

the process of digestive breakdown in various ways.

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Case Study: Gastric Carcinoma

Organs of the Alimentary Canal

The alimentary canal, also called the gastrointestinal tract, is a continuous, coiled,

hollow, muscular tube that winds through the ventral body cavity and is open at both

ends. Its organs are the mouth, pharynx, esophagus, stomach, small intestine and

large intestine. The large intestine leads to the terminal opening or anus. In a cadaver

the alimentary canal is approximately 9 m (about 30 feet) long, but in living person, it is

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considerably shorter because of its relatively constant muscle tone. Food material within

this tube is technically outside the body, because it has contact only with cells lining the

tract and the tube is open to the external environment at both ends.

Mouth

Food enters the digestive tract through mouth

or oral cavity, a mucous membrane- lined cavity. The

lips protect its anterior opening, the cheeks form its

lateral walls, the hard palate forms its anterior roof,

and the soft palate forms its posterior roof. The uvula

is a fleshy fingerlike projection of the soft palate, which

extends downward from its posterior edge. The space

between the lips and cheeks externally and the teeth

and gums internally is the vestibule. The area contained by the teeth is the oral cavity

proper. The muscular tongue occupies the floor of the mouth. The tongue has several

body attachments – two of these are to the hyoid bone in the styloid processes of the

skull. The lingual frenulum, a fold of mucous membrane,

secures the tongue to the floor of the mouth and limits its

posterior movements.

Pharynx

From the mouth, food passes posteriorly into the

oropharynx and laryngopharynx, both of which is common

passageway for food, fluids and air. The pharynx id

subdivided into the nasopharynx, part of the respiratory

passageway; the oropharynx, posterior to the oral cavity; and the laryngopharynx,

which is continuous with the esophagus below.

Esophagus

The esophagus or gullet runs from

the pharynx through the diaphragm to the

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stomach. About 25cm (10inches) long, it is essentially a passageway that conducts food

to the stomach.

Stomach

The C-shaped stomach is on the left

side of the abdominal cavity, nearly hidden

by the liver and diaphragm. The stomach

acts as a “storage tank” for food as well as

a site for the food breakdown. Chemical

breakdown of proteins begins in the

stomach. The mucosa of the stomach is a

simple columnar epithelium that produces

large amounts of mucus.

Most digestive activity occurs in the

pyloric region of the stomach. After food

has been processed in the stomach, it

resembles heavy cream and is called chime. The chime enters the small intestine

through the pyloric sphincters.

Small Intestine

The small intestine is the body’s major digestive organ. Within its twisted

passageways, usable food is finally prepared for its journey into the cells of the body.

The small intestine is a muscular tube extending from the pyloric sphincter to the

ileocecal valve. It is the longest section of alimentary tube with an average length of 2.5-

7m (8-18 feet) in a living person.

The small intestine has three subdivisions: the

duodenum (“twelve finger widths long”), the

jejunum (“empty”) and the ileum (“twisted

intestine”), which contribute 5 percent, nearly

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40% and almost 60% of the length of the small intestine. The ileum joins the large

intestine at the ileocecal valve.

Chemical digestion of foods begins in the nearest in the small intestine. The

small intestine is able to process only a small amount of food at one time. The pyloric

sphincter (gatekeeper) controls food movement into the small intestine from the

stomach and prevents the small intestine from being overwhelmed. Though the C-

shaped duodenum is the shortest subdivision of the small intestine, it has the most

interesting features. Some enzymes are produced by intestinal cells. More important are

enzymes produced by the pancreas which are ducted into the duodenum though the

pancreatic ducts, where they complete the chemical breakdown of foods in the small

intestine. Bile also enters the duodenum through the bile duct in the same area. The

main pancreatic and bile ducts join at the duodenum to form the flash bepatopancreatic

ampulla, literally, the “liver- pancreatic enlargement”. From there, the bile and

pancreatic juice travel through the duodenal papilla and enter the duodenum together.

Nearly all foods absorption occurs in the small intestine.

Large Intestine

The large intestine is much larger in

diameter than the small intestine but

shorter in length. About 1.5m (5 feet) long,

it extends from the ileocecal valve to the

anus. Its major functions are to dry out the

indigestible food residue by absorbing

water and to eliminate these residues from

the body as feces. It frames the small

intestine on the tree sides and has three

subdivisions: cecum, appendix, colon,

rectum and anal canal. The saclike cecum

is the first part of the large intestine. Hanging from the cecum is the wormlike appendix,

a potential trouble spot. The colon is divided into several distinct regions. The ascending

colon travels up the right side of the abdominal cavity and makes a turn, the right colic

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flexure, to travel across the abdominal cavity as the transverse colon. It then turns again

at the left colic flexure, and continues down the left side as the descending colon, to

enter the pelvis, where it becomes the S-shaped sigmoid colon. The sigmoid colon,

rectum, and anal canal lie in the pelvis. The anal canal ends at the anus which opens to

the exterior.

Accessory Digestive Organs

Salivary Glands

Three pairs of salivary glands empty their secretions into the mouth. The large

parotid glands lie anterior to the ears. The submandibular glands and the small

sublingual glands empty their secretions into the floor of the mouth through tiny ducts.

The product of salivary glands, saliva is a mixture of mucus and serous fluids.

The mucus moistens and helps to bind food together into a mass called bolus, which

makes chewing and swallowing easier.

Teeth

We masticate or chew, by opening and closing

our jaws and moving them from side top side while

continually using our tongue to move the food

between our teeth. In the process, the teeth tear and

grind the food, breaking it down into smaller

fragments.

Pancreas The pancreas is a soft, pink, triangular gland

that extends across the abdomen from the spleen to the duodenum. It secretes digestive enzymes into the duodenum, the first segment of the small intestine. These enzymes break down protein, fats, and carbohydrates. The pancreas also makes insulin, secreting it directly into the bloodstream. Insulin is the chief hormone for metabolizing sugar.

Liver

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The liver has multiple functions, but its

main function within the digestive system is to

process the nutrients absorbed from the small

intestine. Bile from the liver secreted into the

small intestine also plays an important role in

digesting fat. In addition, the liver is the body’s

chemical "factory." It takes the raw materials

absorbed by the intestine and makes all the

various chemicals the body needs to function. The liver also detoxifies potentially

harmful chemicals. It breaks down and secretes many drugs.

GallbladderThe gallbladder small, thin-walled green sac that

snuggles in a shallow fossa in the inferior surface of the liver

when food digestion is not occurring, bile backs up the cystic

duct and enters the gallbladder to be stored. While being stored

in the gallbladder, bile is concentrated by the removal of water.

Later, when fatty food enters the duodenum, a hormonal

stimulus prompts the gallbladder to contract to the duodenum

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PATHOPHYSIOLOGY

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Modifiable Factor:Medication(NSAIDS)Lifestyle (Salty foods)Hygiene

Non-Modifiable Factors:AgeBlood type

upsets gastric acid secretory physiology to varying degrees

Development of Gastric Ulcers and tissue injury

Altered Gastric Secretion

Cellular Mutation

Persistent Immune Stimulation of Gastric lymphoid tissue

Gastric Lymphoma

Helicobacter Pylori Infection

Renders the mucosa more vulnerable to acid damage

by disrupting mucous layer, liberating enzymes and

toxins&adhering to gastric epithelium

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Pathophysiology

Helicobacter pylori infection is the cause of most stomach cancer. It is unclear

how H. pylori infection spreads. The bacteria probably spread from one person to

another  through poor hygiene as the bacteria may be passed in stools. The bacterium

generally does not invade gastroduodenal tissue. Instead, it renders the underlying

mucosa more vulnerable to acid peptic damage by disrupting the mucous layer,

liberating enzymes and toxins, and adhering to the gastric epithelium. Gastric polyps

are precursors of cancer. Inflammatory polyps may develop in patients taking NSAIDs

and too much salty foods is also a risk factor.

The chronic inflammation induced by H. pylori and damage caused by other factors

upset gastric acid secretory physiology to varying degrees causing an altered gastric

secretion. The increased acid secretion leads to the development of gastric ulcers and

tissue injury. These damages causes cellular mutation or changes in the DNA of the

cells. Immune responses induced by the changes causes persistent stimulation of

gastric lymphoid tissue and development into gastric lymphoma.

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Preventive Management and

Treatment

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Prevention:Screening Programs

Annual mass screening for gastric cancer has been provided in some countries with a high incidence of gastric cancer (such as Japan, Venezuela, and Chile) with the aim of detecting gastric cancer in its earliest stages when the prognosis is better.

VaccinationVaccine against Helicobacter Pylori is still in progress.

The following may help reduce your risk of gastric cancer:

Don't smoke Eat a healthy, balanced diet rich in fruits and vegetables Taking a medication to treat reflux disease, if present Decrease intake of preserved foods

Treatment:

As with any cancer, treatment is adapted to fit each person's individual needs and depends on the size, location, and extent of the tumor, the stage of the disease, and general health. Cancer of the stomach is difficult to cure unless it is found in an early stage (before it has begun to spread). Unfortunately, because early stomach cancer causes few symptoms, the disease is usually advanced when the diagnosis made. Treatment for stomach cancer may includes surgery, chemotherapy, and/or radiation therapy. New treatment approaches such as biological therapy and improved ways of using current methods are being studied in clinical trials.

Surgery

Surgery is the most common treatment and is the only hope of cure for stomach cancer. The surgeon removes part or all of the stomach, as well as the surrounding lymph nodes, with the basic goal of removing all cancer and a margin of normal tissue. Depending on the extent of invasion and the location of the tumor, surgery may also include removal of part of the intestine or pancreas. Tumors in the lower part of the stomach may call for a Billroth I or Billroth II procedure. Endoscopic mucosal resection (EMR) is a treatment for early gastric cancer (tumor only involves the mucosa) that has been pioneered in Japan, but is also available in the United States at

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some centers. In this procedure, the tumor, together with the inner lining of stomach (mucosa), is removed from the wall of the stomach using an electrical wire loop through the endoscope. The advantage is that it is a much smaller operation than removing the stomach. Endoscopic submucosal dissection (ESD) is a similar technique pioneered in Japan, used to resect a large area of mucosa in one piece. If the pathologic examination of the resected specimen shows incomplete resection or deep invasion by tumor, the patient would need a formal stomach resection.

Surgical interventions are currently curative in less than 40% of cases, and, in cases of metastasis, may only be palliative.

Chemotherapy

The use of chemotherapy to treat stomach cancer has no established standard of care. Unfortunately, stomach cancer has not been especially sensitive to these drugs until recently, and historically served to palliatively reduce the size of the tumor and increase survival time. Some drugs used in stomach cancer treatment include: 5-FU (fluorouracil), BCNU (carmustine), methyl-CCNU (Semustine), and doxorubicin (Adriamycin), as well as Mitomycin C, and more recently cisplatin and taxotere in various combinations. The relative benefits of these drugs, alone and in combination, are unclear. Scientists are exploring the benefits of giving chemotherapy before surgery to shrink the tumor, or as adjuvant therapy after surgery to destroy remaining cancer cells. Combination treatment with chemotherapy and radiation therapy is also under study. Doctors are testing a treatment in which anticancer drugs are put directly into the abdomen (intraperitoneal hyperthermic chemoperfusion). Chemotherapy also is being studied as a treatment for cancer that has spread, and as a way to relieve symptoms of the disease. The side effects of chemotherapy depend mainly on the drugs the patient receives.

Radiation therapy

Radiation therapy (also called radiotherapy) is the use of high-energy rays to damage cancer cells and stop them from growing. When used, it is generally in combination with surgery and chemotherapy, or used only with chemotherapy in cases where the individual is unable to undergo surgery. Radiation therapy may be used to relieve pain or blockage by shrinking the tumor for palliation of incurable disease

Multimodality therapy

While previous studies of multimodality therapy (combinations of surgery, chemotherapy and radiation therapy) gave mixed results, the Intergroup 0116 (SWOG 9008) study showed a survival benefit to the combination of chemotherapy and radiation

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therapy in patients with nonmetastatic, completely resected gastric cancer. Patients were randomized after surgery to the standard group of observation alone, or the study arm of combination chemotherapy and radiation therapy. Those in the study arm receiving chemotherapy and radiation therapy survived on average 36 months; compared to 27 months with observation.

Specific Treatment for Gastric Lymphoma

 Lymphomas of the stomach are primarily treated with chemotherapy with CHOP with or without rituximab being a usual first choice.

CHOP – Cyclophosphamide, hydroxydaunorubicin (doxorubicin), Oncovin (vincristine) and Prednisone/Prednisolone.

This regimen can also be combined with the monoclonal antibody rituximab if the lymphoma is of B cell origin; this combination is called R-CHOP or CHOP-R. Typically, courses are administered at an interval of two or three weeks (CHOP-14 and CHOP-21 respectively). A staging CT scan is generally performed after three cycles to assess whether the disease is responding to treatment.

Antibiotic treatment to eradicate H. pylori is indicated as first line therapy for MALT lymphomas. About 60% of MALT lymphomas completely regress with eradication therapy. Second line therapy for MALT lymphomas is usually chemotherapy with a single agent, and complete response rates of greater than 70% have gain been reported.

Subtotal gastrectomy, with post-operative chemotherapy is undertaken in refractory cases, or in the setting of complications, including gastric outlet obstruction.

Treatment of H.Pylori infections with combinations of antibiotics and acid inhibitors successfully limits the infection and eventually eradicates the bacteria from the stomach.

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Case Study: Gastric Carcinoma

Health Teaching

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Case Study: Gastric Carcinoma

Patient and Family Health Teaching

Advise patient to comply medications as prescribed by the physician.

Advise the family to maintain a clean and safe environment. Do tepid sponge bath if fever occurs. Encourage proper hygiene of the patient and family. Keep the area around the jejunostomy tube clean and dry. If the surgical wound(jejunostomy) has already healed, do not keep

the site covered with gauze to avoid moisture and skin breakdown. Proper preparation and storage of food Fruits and vegetables in everyday meal Avoid too much alcoholic foods Limit salty foods and foods with preservatives

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Nursing Care Plan

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Case Study: Gastric Carcinoma

41 Case Study: Gastric Carcinoma

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATIONACTION RATIONALE

Subjective:“Hindi na ako makakain kaya namayat ako ng ganito” as verbalized.

Objective: Thin

extremities Weakness Diet: NPO With an IVF

of D5NSS With

jejunostomy tube

Decreased subcutaneous fat

Poor muscle tone

Imbalanced Nutrition: less than body requirements r/t dysphagia and surgical procedure secondary to gastric carcinoma

After the medical and nursing management, the patient will be able to acquire adequate nutrition

Assess nutritional status continually, during daily nursing care, noting energy level; condition of skin, nails, hair, oral cavity

Weigh daily

Document parenteral intake and calorie counts as appropriate

Provides the opportunity to observe deviations from normal patient baseline, and influences choice of interventions.

Establishes baseline, aids in monitoring effectiveness of therapeutic regimen, and alerts nurse to inappropriate trends in weight loss/gain.

Identifies imbalance between estimated nutritional requirements and actual intake.

At the end of the medical and nursing interventions, the patient will be able to regain appropriate weight.

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Administer nutritional solutions at prescribed rate. Adjust rate to deliver prescribed hourly intake

Schedule activities with adequate rest periods. Promote relaxation techniques.

Administer medications as indicated(vitamin K)

Nutrition support prescriptions are based on individually estimated caloric and protein requirements. A consistent rate of nutrient administration ensures proper utilization with fewer side effects, such as hyperglycemia or dumping syndrome

Conserves energy/reduces calorie needs.

Vitamins are given for identified deficiencies.

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATIONACTION RATIONALE

Subjective:“Nanghihina pa rin ako” as verbalized.

Objective: Weak in

appearance Thin

extremities Frequently

asleep Poor muscle

tone

Risk for Infection r/t malnutrition and surgically placed jejunostomy tube

After 8 hours of nursing intervention, the patient will remain free of signs of infections and other complications.

Stress/model proper handwashing technique.

Maintain sterile technique for invasive procedures. Provide routine site/wound and perineal care

Encourage frequent position changes

Screen visitors/care providers for infectious processes, especially URI.

Assess vital signs

Reduces risk of cross-contamination

Prevents entry of bacteria, reducing risk of nosocomial infections.

Limits stasis of body fluids, promotes optimal functioning of organ systems, GI tract.

Reduces risk of transmission viruses that are difficult to treat.

A rise in pulse and temperature may provide warning of infectious process unless patient’s

At the end of the nursing intervention, the patient will show no signs of infections/complications as evidenced by normal vital signs.

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Keep the surgical site clean and dry. Maintain a sterile occlusive dressing over catheter insertion site.

Aseptically prepare parenteral solutions

Administer antibiotics as indicated.(cefuroxime)

Keep linen dry and free of wrinkles

immune system is too compromised to respond.

Protects catheter insertion sites from potential sources of contamination

Prevents potential contamination

May be given prophylactically or for specifically identified organism.

Moist and wrinkles on the linen provides susceptibility for bacterial growth.

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Case Study: Gastric Carcinoma

Drug Study

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VITAMIN KPhytonadione

Classification DosageMode Of Action

Indication Contraindication Adverse EffectsNursing

Responsibility

Vitamin/ Supplement

1amp IVP then q6°x3doses

Promotes hepatic synthesis of activeprothrombin, proconvertin, plasmathromboplastin component, and Stuartfactor

➣Hypoprothrombinemia caused byanticoagulant therapy➣Hypoprothrombinemia secondary to other causes

● Contraindicated in hypersensitivityto drug or its components. (Life-threateningreactions resembling hypersensitivityor anaphylaxis have occurredduring and immediately after I.V.injection.)● Use cautiously in pregnant or breastfeedingpatients, children, and neonates(if product contains benzyl alcohol).● Avoid P.O. use in disorders that mayprevent adequate absorption.

Hyperbilirubinemia (in infants); withparenteral administration—pain, swelling,tenderness at injection site; itchyrash after repeated injections; transientflushing sensations; peculiar taste; anaphylactoidreactions

.>Observe for allergic reactions: flushed skin, nausea, rash, and itching. Medical attention should be sought if any of these symptoms occur.>Use cautiously in certain types of liver problems.

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PARACETAMOLAcetaminophen

Classification DosageMode Of Action

Indication Contraindication Adverse EffectsNursing

ResponsibilityAnalgesic, antipyretic

300mg IV q4°PRN ANST(-)

Unclear. Pain relief may result from inhibitionof prostaglandin synthesis in CNS,with subsequent blockage of pain impulses.Fever reduction may result fromvasodilation and increased peripheralblood flow in hypothalamus, which dissipatesheat and lowers body temperature.

➣Mild to moderate pain caused byheadache,muscle ache, backache, minorarthritis, common cold, toothache,or menstrual cramps or fever

● Hypersensitivity to drug

Hematologic: thrombocytopenia, hemolyticanemia, neutropenia,leukopenia, pancytopeniaHepatic: jaundice, hepatotoxicityMetabolic: hypoglycemic comaSkin: rash, urticariaOther: hypersensitivity reactions (suchas fever)

Observe for acute toxicity and overdose.● Caution parents or other caregiversnot to give acetaminophen to childrenyounger than age 2 without consulting prescriber first.● Tell patient, parents, or other caregivers not to use drug concurrently with other acetaminophen-containing products.● Advise patient, parents, or othercaregivers to contact prescriber if fever or other

48 Case Study: Gastric Carcinoma

symptoms persist despite taking recommended amount of drug.● Inform patients with chronic alcoholism that drug may increase risk of severe liver damage.● As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and behaviors mentioned above.

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KETOROLACKetorolac Tromethamine

Classification DosageMode Of Action

Indication Contraindication Adverse EffectsNursing

Responsibility

Nonsteroidalanti-inflammatory drug (NSAID,

30mg SIVP q6°ANST(-)

Interferes with prostaglandin biosynthesisby inhibiting cyclooxygenase pathwayof arachidonic acid metabolism;also acts as potent inhibitor of plateletaggregation

➣Moderately severe acute pain➣Ocular itching caused by seasonal➣Postoperative ocular inflammationrelated to cataract extraction➣To reduce ocular pain, burning, orstinging after corneal refractive surgery

● Hypersensitivity to drug, its components,aspirin, or other NSAIDs● Concurrent use of aspirin, otherNSAIDs, or probenecid● Peptic ulcer disease● GI bleeding or perforation● Advanced renal impairment, risk ofrenal failure● Increased risk of bleeding, suspectedor confirmed cerebrovascular bleeding,hemorrhagic diathesis, incomplete hemostasis● Prophylactic use

CNS: drowsiness, headache, dizzinessCV: hypertensionEENT: tinnitusGI: nausea, vomiting, diarrhea, constipation,flatulence, dyspepsia, epigastricpain, stomatitisHematologic: thrombocytopeniaSkin: rash, pruritus, diaphoresisOther: excessive thirst, edema, injectionsite pain

● Be aware that oral therapy is indicatedonly as continuation of parenteraltherapy.●Know that parenteral therapyshouldn’t exceed 20 doses in 5 days.● For I.V. use, dilute with normal salinesolution, dextrose 5% in water, dextrose5% and normal saline solution, Ringer’ssolution, or lactated Ringer’s solution.● Administer single I.V. bolus over 1 to

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before major surgery,intraoperative use when hemostasisis critical● Labor and delivery● Breastfeeding

2 minutes.● Inject I.M. dose slowly and deeply.● Don’t give by epidural or intrathecalinjection.● Monitor for adverse reactions, especiallyprolonged bleeding time andCNS reactions.● Check I.M. injection site for hematomaand bleeding.● Monitor fluid intake and output.

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CEFUROXIMECefuroxime Axetil

Classification DosageMode Of Action

Indication Contraindication Adverse EffectsNursing

Responsibility

Second generationcephalosporin

750mg SIVP q8° ANST (-)

Interferes with bacterial cell-wall synthesisand division by binding to cellwall, causing cell to die. Active againstgram-negative and gram-positivebacteria, with expanded activityagainst gram-negative bacteria.Exhibits minimal immunosuppressant

➣Moderate to severe infections, includingthose of skin, bone, joints, urinaryor respiratory tract, gynecologicinfections➣Gonorrhea➣Bacterial meningitis➣Otitis media➣Pharyngitis; tonsillitis

● Hypersensitivity to cephalosporinsor penicillins● Carnitine deficiency

CNS: headache, hyperactivity, hypertonia,seizuresGI: nausea, vomiting, diarrhea, abdominalpain, dyspepsia, pseudomembranouscolitisGU: hematuria, vaginal candidiasis,renal dysfunction, acute renal failureHematologic: hemolytic anemia,aplastic anemia, hemorrhageHepatic: hepatic dysfunctionMetabolic: hyperglycemiaSkin: toxic epidermal necrolysis, erythema

.● Reconstitute drug in vial with sterilewater for injection.● Give by direct I.V. injection over 3 to5 minutes into large vein or flowingI.V. line.● For intermittent I.V. infusion,reconstitute drug with 100 ml ofdextrose 5% in water or normal salinesolution; administer over 15 minutesto 1 hour. For continuous infusion,give in 500 to 1,000 ml of compatible

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activity. multiforme, Stevens-JohnsonsyndromeOther: allergic reaction, drug fever, superinfection,anaphylaxis

solution; infuse over 6 to 24 hours.● Inject I.M. doses deep into largemuscle mass.● Give oral form with food.● Be aware that tablets and oral suspensionare exchangeable on a milligram-for-milligram basis.

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Case Study: Gastric Carcinoma

EVALUATION

After 2 days of confinement, diagnostic procedure(CT scan) confirmed the diagnosis of gastric lymphoma. An exploratory laparotomy and jejunostomy were done to the patient and she was placed on NPO. 3 days after the surgery, weakness is still present. The patient is still on NPO with parenteral nutrition provided. Laboratory result shows high random blood sugar which may be due to prolonged infusion of parenteral nutrition. It is also shown is laboratory results that there are decreased values of MCV, MCH and MCHC which are indicative of anemia. Health teachings should be provided to the patient as well as to the family since they are the primary care giver, in order to prevent the development of further infections and complication and to prevent any other family member from developing the same disease. And they should comply to the therapeutic regimen as ordered. They should be able to show proper jejunostomy tube care and if the patient shall be discharged, she should be referred to an infusion home healthcare worker to make sure she would be set at home for proper nutrition.

BIBLIOGRAPHY

Book References:Brunner and Suddarth,s Textbook of Medical and Surgical NursingTenth EditionSuzanne C. Smeltler, Brenda G. Bare

Essentials of Anatomy and Physiology8th EditionElaine Marieb

Eternal Links:www.nlm.nih.gov/medlineplus/ency/article/000223.htmen.wikipedia.org/wiki/Stomach_canceremedicine.medscape.com/article/375384-overviewwww.google.com

Others:Patient’s Chart