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Julio Alejandro Murra-Saca MD.
Gastroenterologist
Tel : (503) 226-3131, (503) 225-3087, Celular (503) 887-2507
Email
  
Edificio Centro Scan, Colonia Médica, San Salvador, El Salvador.

 

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Notes on Cyber Gastroenterology

 

Gastric Cancer is one of the most frequent malignant tumors in El Salvador, which is responsible for numerous causes of deaths per year.

Internationally: Adenocarcinoma of the stomach is the second most common cancer worldwide.

.Risk for gastric (stomach) cancer increases with age. Evidence suggests that high salt intake, a diet low in fresh fruits and vegetables, and infection with H. pylori are associated with an
increased risk of gastric cancer; whereas diets high in whole grain cereals, carotene, and
green tea are associated with a reduced risk of this cancer.

Early detection is often difficult because the symptoms are often vague. They include weakness, fatigue, decreased appetite, indigestion, abdominal pain and bloating. The detection of blood in the stool may indicate a gastric cancer, but can also be caused by many other things. People with continuous gastric symptoms should seek medical attention.

Gastric cancer is one of the most frequent cancers not only in El Salvador but also in the majority of the countries of Latin America as well as in Japan.

Gastric Cancer is the second most common cause of cancer-related death in the world. Many Asian countries, including Korea, China, Taiwan, and Japan, have very high rates of gastric cancer. More than 22,000 new cases will be diagnosed this year in the United States, making gastric cancer the fourteenth most common cancer in this country. while in the US, the incidence of stomach cancers has actually decreased over the past decade, accounting for approximately 21,000 new cases and 13,000 cancer-related deaths last year. Some of this decrease may be attributable to widespread antimicrobial therapy for eradication of Helicobacter pylori, which harbors a strong association with gastric cancer and the decreased use of salted and smoked foods.
Other risk factors associated with increased incidence of gastric cancers include cigarette smoking, alcohol abuse, and nitrosoamine intake. Benign adenomas, which are the gastric counterpart of colorectal adenomas, are also associated with a risk of progression to cancers. The vast majority (90-95%) of gastric cancers are gland-forming adenocarcinomas. Other less common tumors of the stomach include lymphomas, carcinoids and gastric stromal tumors. Epidemiologic studies have shown that the two major histologic subtypes of gastric adenocarcinomas - the intestinal (well differentiated) type and diffuse (poorly differentiated) type - arise by distinct pathways. The intestinal type is strongly associated with Helicobacter pylori, and usually arises on a backdrop of chronic gastritis, gastric atrophy, and intestinal metaplasia. In contrast, poorly differentiated adenocarcinomas are usually not associated with these changes.Clinically, the latter often present with diffuse thickening of the stomach wall, rather than a discernible mass (linitis plastica). The intestinal adenocarcinomas have a better prognosis than the diffuse variant, most of which have spread beyond the confines of the stomach at the time of diagnosis. As with other cancers, stage is the most important determinant of outcome. In Japan, intensive screening modalities have led to the emergence of a new variant called early gastric cancers, in which the primary tumor is restricted to the mucosa or submucosa, irrespective of metastasis, at the time of detection.
Click on the Image to download the video  clip.
Endoscopic and video clip view of Doughnut shaped Gastric Carcinoma of the antrum in a 44 year- old male .Click on the image to download the video clip to appreciate in full screen wait to be downloaded and press Alt and Enter.


Obtaining a high curability rate depends on early diagnosis. When diagnosed in an early phase
Gastric Cancer is almost completely curable. The major importance of Endo- scopy, is the possibility of early detection. With Endoscopy, and specially with the introduction of high resolution videoendoscopes We now count with a diagnostic tool that permits exact and complete visualization of the upper G.I. tract or Colon, including the possibility to store the film on Video tapes of different formats like VHS, UMATIC, BETACAM or DIGITALIS.
Unfortunately, patients who have stomach cancer rarely have symptoms in the early stages of the disease. This is one of the reasons why stomach cancer is so difficult to detect early.
The signs and symptoms of stomach cancer include:
Unintended weight loss and lack of appetite.
Abdominal pain.
Vague discomfort in the abdomen, usually above the umbilicus (navel).
A sense of fullness in the upper abdomen, just below the chest bone after eating a small meal. Doctors call this early satiety.
Heartburn, indigestion, or ulcer-type symptoms Nausea Vomiting, with or without blood.
Swelling of the abdomen due to accumulation of fluid and cancer cells. Doctors call this malignant ascites.

Gastric cancer is the second most common cause of cancer-related death in the world. Many Asian countries, including Korea, China, Taiwan, and Japan, have very high rates of gastric cancer. More than 22,000 new cases will be diagnosed this year in the United States, making gastric cancer the fourteenth most common cancer in this country.
Age: Most patients are elderly at diagnosis. The median age at diagnosis is 65 years (range 40-70 y). The gastric cancers that occur in younger patients may represent a more aggressive variant.

Mucosectomy EMR: Endoscopic Treatment for early gastric carcinoma.
Endoscopic mucosal resection, also known as endoscopic resection, is defined as the resection of
a fragment of the digestive wall including the mucosal membrane and the muscularis mucosae. This resection most frequently removes a part or even all of the submucosa. Mucosectomy is a curative endoscopic procedure which is for intramucosal cancers (also called in situ cancers).Treatments for stage IA ( T1N0 ). EMR is indicated for patients with small mucosal cancer with no lymph
node metastases.
Weight loss and persistent abdominal pain are the most common symptoms at initial diagnosis.
Weight loss usually results from insufficient caloric intake rather than increased catabolism, and may be attributable to anorexia, nausea, abdominal pain, early satiety, and/or dysphagia.

The abdominal pain tends to be vague and mild early in the disease, but more severe and constant as the disease progresses.

Dysphagia is a common presenting symptom in patients with cancers arising in the gastric cardia or at the esophagogastric junction.


Patients may also present with nausea or early satiety from gastric outlet obstruction or gastric stasis related to tumor infiltration of the stomach wall. Occult gastrointestinal bleeding with or without iron deficiency anemia is common, while overt bleeding (ie, melena or hematemesis) is seen in only 20 percent of cases. The presence of a palpable abdominal mass is the most common physical finding and generally indicates long-standing, advanced disease

A pseudoachalasia syndrome may occur as the result of involvement of Auerbach's plexus due to local extension or to malignant obstruction near the gastroesophageal junction. For this reason, gastric cancer needs to be considered in the differential diagnosis for older patients presenting with achalasia
 
Prognosis and staging
The prognosis is related to the stage of the disease at the time of diagnosis and to the histologic grade of the carcinoma.
Pathologic staging is based on the tumor, nodes, and metastases (TMN) stage.
• T stage - Extent of penetration through the gastric wall
o Tis - Carcinoma in situ, intraepithelial tumor
o T1 - Tumoral extension to submucosa
o T2 - Tumoral extension to the muscularis propria or subserosa
o T3 - Tumoral penetration of the serosa
o T4 - Tumoral invasion of the adjacent organs
• N stage - Number and site of draining lymph nodes involved (see also N staging below)
o N0 - No lymph nodes involved
o N1 - Metastases in 1-6 regional lymph nodes
o N2 - Metastases in 7-15 regional lymph nodes
o N3 - Metastases in >15 regional lymph nodes
• M stage - Presence of metastases
o M0 - No distant metastases
o M1 - Distant metastases
Staging and 5-year survival

Stage TNM Stage 5-Year Survival
1 T1N0M0, T1N1M0, or T2N0M0 88%
2 T1N2M0, T2N1M0, or T3N0M0 65%
3a T2N2M0, T3N1M0, or T4N0M0 35%
3b T3N2M0 35%
4 T4N1-3M0, TxN3M0, or TxNxM1 5%

*Tx indicates any T stage; Nx, any N stage.



SURGICAL TREATMENT OF GASTRIC CANCER

SUMMARY: The management of stomach cancer patients is discussed under the following headings: incidence, etiology (cancer developing after previous operation for benign ulcer), epidemiology, pathology (fungating tumors; ulcerating tumors; diffuse or infiltrating tumors), histology (histologic classification; Broders' classification; site of origin; spread of gastric carcinoma; extension of carcinoma from other organs to the stoma), symptoms, physical examination, roentgenologic diagnosis (polypoid tumors; infiltrative cancer; the peptic ulcer syndrome; cancer of the stomach after gastric surgery; demonstration of metastases), gastroscopy (endoscopy), cytology, laboratory studies, exploratory laparotomy (preoperative evaluation; evidence of metastasis; preparation of the patient for operation), definitive treatment (surgical treatment), results (TNM classification; factors affecting survival), management of the patient with incurable gastric cancer (effectiveness of noncurative operations in affording palliation; duration of life; relief of symptoms; mortality rate; long-term results; prospects for the future), malignant tumors of the stomach other than carcinoma (malignant lymphoma; end results), and nonlymphomatous sarcomas (diagnosis; treatment; end results). The subheading dealing with diffuse or infiltrating tumors gives consideration to diffusely infiltrating cancer, superficial spreading carcinoma, and linitis plastica. That dealing with histologic classification gives consideration to carcinoma in situ, adenocarcinoma, and gelatinous or mucoid adenocarcinoma. That dealing with endoscopy gives consideration to Type I (protruded type), Type II (superficial type), and Type III (excavated type) tumors. That dealing with surgical treatment gives consideration to local excision, surgical treatment of benign gastric ulcer, and surgery for palliation. That dealing with diagnosis of nonlymphomatous sarcomas gives consideration to roentgenologic diagnosis, gastroscopy, and cytology.
The operation you have to remove your stomach cancer will depend on where in the stomach the cancer is. You may be offered a
Partial gastrectomy
Total gastrectomy
Oesophagogastrectomy
These are all major operations and it takes time to get over them. Your doctor must be sure you are fit enough to get through a long operation and anaesthetic and make a good recovery.

If your cancer has spread to another organ, you are less likely to be offered any of these operations as they will not cure your cancer. But an operation to remove the tumour may be done if it is blocking your stomach.

Partial gastrectomy
If your cancer is at the end of the stomach that connects with the duodenum you may have only part of your stomach removed. This is called a partial gastrectomy. After the operation you will have a much smaller stomach but the valve (cardiac sphincter) between your gullet and stomach will still be there. The scar from the operation will be across your abdomen. There are 2 different types of this operation. They are called Bilroth 1 and Bilroth 2. Bilroth 1 operations are not done very often these days.

Removing lymph nodes
During your operation you will have all of the lymph nodes close to the stomach removed. This is because they may contain cancer cells that have broken away from the main cancer. Taking them out reduces the risk of your cancer coming back in the future.

It is not yet clear from clinical trials whether removing more lymph nodes from the area surrounding the stomach reduces the risk of the cancer coming back even further. Doctors are waiting for the results of a clinical trial looking at this in detail.

What happens if my stomach is removed?
If only part of your stomach is removed you will have to eat small amounts of food more often, at least for a while, until your system learns to cope with a smaller stomach capacity. The stomach that is left will gradually stretch so that you can eat more at a time.

If your whole stomach is removed, you may eventually return to eating normally, but this will take longer. You will also have to have injections of vitamin B12 for the rest of your life to prevent anaemia and nerve problems.

It is common to have diarrhoea for some months after stomach surgery. This can be very upsetting and you may feel weak for a time.

 

Please click the image to download the video clip.
66 year old female who complained of epigastric pain for about six months.
We performed an upper G.I. tract Video Endoscopy and obtained an image displayed as a small nodule with a tiny ulcer. The histopatologic study revealed a Gastric Carcinoma in an early stage.
Please click on the image to download the video clip .
To appreciate the video we recommended that you configure the media player in repeat and when the video is running press Alt + Enter for Full Screen.
 
Patient with advanced gastric adenocarcinoma. CT, transverse cross-section, showing ascitis and hepatic metastasis.  

 

Please click the image to downloas the video clip.
Ulcerated Gastric Carcinoma of the gastric corpus.
To optain more endoscopic details see the video clip by clicking on the image.

 

 

Gastric carcinoma of the body , Click the image to download the video clip.
54 years old male. Gastric endoscopy reveled gastric carcinoma of the corpus.
This tumor is initially asymptomatic. Advanced cases present with abdominal discomfort or pain, anorexia, nausea, vomiting, anemia due to loss of blood, dysphagia, weight loss and changes in the bowel habits.


Fore more endoscopic details please download the video clip by clicking on the image

62 year old woman with anemia and weight loss, more than 20 pounds
Large carcinoma of the antrun causing hight-grade stenosis

For more endoscopic details please click on the image to download the video clip
57 years old female who had a history of previous upper gastrointestinal endoscopies over several years, performed elsewhere.. On her first visit to our clinic she complained of epigastric pain and disuria. A severe urinary tract infection was detected and ciprofloxacine was prescribed.
The next morning an upper gastrointestinal Endoscopy was performed and a tablet of ciprofloxacine taken at 3 am, was found at the cardias (the endoscopy was performed at 9.11 am) The tablet still being in the esophagus is not considered normal since foods and medicines travel immediately to the stomach, after being ingested. Thus suspicion of a disease in this region is awakened. (See next photography. ).

For more endoscopic details please click on the image to download the video clip

Same case as previous one, Ulcerated Gastric Carcinoma of the fundus, retroflexed maneuver.

Click the image to download the video clip.

Infiltrating Gastric carcinoma of the body, that resembles erosive gastritis.
Brother of a former President of the Republic of El Salvador.
Click on the image to download the video clip.

Click the Image to Download the video clip.

Ulcerated Gastric Carcinoma at the gastric angle.

For more endoscopic details please download the video clip by clicking on the image.

Doughnut shaped Gastric carcinoma that obstructed the antrum.

Click on the image to download the video clip.

Gastric carcinoma of the fundus

Click on the image to download the video clip.

Ulcerated Gastric Carcinoma of the antrum.

Click the image to download the video clip.

94 years old female, Cauliflower like Gastric Carcinoma

Please click on the image to  download  the video clip.

77 yeas old male, Gastric Carcinoma of the body.

Click the image to download the video clip.

70 years old male with ulcerated Gastric carcinoma of
the body.
Click on the image to download the video clip.


Please click the image to download  the video clip.
81 years old male, Antrum Gastric Carcinoma

Click on the image to download the video clip.
58 years old female, Ulcerated Carcinoma of the Antrum

.

62 years old Female, Carcinoma of Gastric body. A nodule and irregularity at the union of the gastric fold is observed.

Click on the image to download the video
84 years old male. Ulcerated Gastric Carcinoma of
fundus with signet ring cells.

Photography of Infiltrating and ulcerated Gastric Carcinoma , 70 years old male.


64 years old male, Ulcerated Gastric Carcinoma
that infiltrate the Gastric antrum.

For more endoscopic details please download the video clip by clicking on the image.
50 years old female, weight loss of 20 twenty pounds,
doughnut shapde Antrum Gastric Carcinoma.


65 years old male with small irregular ulceration at the
Gastric body, histopatologic study revealed gastric cancer
signet ring cells.

Presionar la imagen para descargar el video
76 years old male who came with his family Doctor
asking for a gastric endoscopy. Enormous tumor of the corpus and fundus
in antrum area. There are gastric polyps, reason why it think that this carcinoma is degenerated from a polyp " The theory adenoma Carcinoma"

Presionar la imagen para descargar el fragmento del video.
Female 67 years old that had been treated by his internist Doctor, Complaining of sensation of " small ball " in epigastric. She was sent to undergo an abdominal ultrasound which was negative. Later a barium enema examination was performed with emphasis on the hepatic angle, which was negative. Therefore the internist prescribed a topical oiment for this sensation. As she did not improve the patient arrived at my clinic, a mass of great size was felt .
An upper endoscopy examination was performed and a enormous adenocarcinoma was found. At time of surgery the tumor was considered inoperable due to its advanced stage of the disease. The ultimate decision as to operability of the tumor is made at the time of laparatomy.

Please click on the image to download the video clip.
45 years old Female with Carcinoma of the antrum with obstructive signs. Nevertheless the Endoscopic diagnostic was delayed because patient had multiple antiulcer prescriptions for over six months with different doctors and different treatments without any special medical examination like endoscopy etc.
This clinical history is repeated frequently since most of these people believe that they have an ulcer or gastritis or are being told so by their doctor or any other person, without having undergone any special exams (i.e. endoscopy). An ulcer or gastritis treated with modern medicines, improves at the present time in three or four days, and cure is expected within one month to six weeks..
Please click on the image to download the video clip.
51 years old male, brother of prestigious pediatric surgeon who
ask to perform an upper endoscopy, we found these antrum carcinoma
the image display above is after one years of the diagnosis, carcinoma was
inoperable the image is after Chemotherapy and radiations.
Please click on the image to download the video clip.
Post surgical status of previous case.

Favor de presionar la imagen para descargar los fragmentos de video.
Gastric Carcinoma that causes antrum obstruction.

Presionar la imagen para descargar el fragmento del video.

Gastric carcinoma that causes antrum obstruction.

For more endoscopic details please download the video clip by clicking on the image.
72 years old male with gastric carcinoma of the fundus that causes
bleeding.


73 years old male with small nodule at the antrum. The biopsy
displayed signet ring carcinoma.

For more endoscopic details please download the video clip by clicking on the image.
78 years old female, Gastric Carcinoma that makes obstruction
at the antrum, bile reflux is observed.

Presionar la Imagen para descargar los fragmentos de videos.
73 years old male with enormous ulcerated gastric carcinoma
of the antrum and gastro angle.

For more endoscopic details please download the video clip clicking on the image.
50 years old male with obstructed Gastric Carcinoma

 

See the video clip.
76 years old female with obstructed Gastric Carcinoma of the
Cardias.

For more endoscopic details please download  the video clip by clicking on the image
69 years old male with progressive dysphagia,weigh loss of twenty
pounds and sialorrea, Carcinoma of the cardias and gastric fundus.
See next images.

For more endoscopic details please download  the video clip by clicking on the image
Retroflexed manner same case of the previous image, necrotizing
gastric carcinoma of the fundus


Same case of the previous images, carcinomatous band of the corpus.

Please download the video clip.
Advanced Gastric Carcinoma
35 years old Salvadorean Female who was living in the United State
presented jaundice, diagnosed as hepatitis A she was managed on outpatient
basis for fifteen days, during which she worsened and was hospitalized
patient came to El Salvador for a second opinion without providing much patient
information.


Image of the previous case. Gastric Carcinoma that infiltrates entire
stomach. Fundus is observed at the retroflexed maneuver.


Photograph of the previous case. The corpus is infiltrated and ulcerated.


Same case as above. Carcinoma with elevated margin in the
area of the antrum.
For more endoscopic details please download the video clñip by clicking on the image.
60 years old male, extensive Gastric Carcinoma.


Same case as above. Extensive Gastric Carcinoma.

 

Cáncer Gástrico For more endoscopic details please download the video clñip by clicking on the image.
75 years old female, Ulcerated Gastric Carcinoma. In the area
of the lesser curvature.
For more endoscopic details please download the video clñip by clicking on the image.
67 yeas old female, prepyloric carcinoma.

 

 For more endoscopic details please download the video clñip by clicking on the image.
47 years old male with gastric carcinoma of the antrum.

Click on the Image to Download the video clip.
61 years old male, gastric carcinoma causing high-grade stenosis.
Several ulcers are observed at the corpus and fundus.

For more endoscopic details please download the video clñip by clicking on the image.
Gastric Carcinoma of the Cardias
69 years old male, was seen in the emergency room of the Social security
Hospital for upper GI tract bleeding and was diagnosed as having erosive gastritis
the patient condition worsen and he ask for a second opinion.
Note: It is necessary to always perform a follow-up endoscopy after initial emergency room gastroscopy, when dealing with upper GI track hemorrhage
because the blood will diminish the sensitivity of the emergency room procedure.

For more endoscopic details please download the video clñip by clicking on the image.
Same case as above, Gastric Carcinoma of the cardias extending
into the esophagus, inversion maneuver.

For more endoscopic details please download the video clñip by clicking on the image.
72 years old male with an extensive Gastric Carcinoma.
Patient have long history of dyspepsia, after developing obstructive symptoms
patient consulted general practitioner who refer patient to me for endoscopy.

For more endoscopic images and video clips see
El Salvador Atlas of Gastrointestinal VideoEndoscopy

 

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