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.

Case Study: Gastric Carcinoma

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.

Case Study: Gastric Carcinoma

INTRODUCTION: Background of the Disease

Case Study: Gastric Carcinoma

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.

Risk Factors:
Risk factors for gastric lymphoma include the following:

Case Study: Gastric Carcinoma

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 weight loss Nausea and Vomiting

6
Anorexia Weakness Dysphagia

Case Study: Gastric Carcinoma

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 tumor o T1 - Tumor extension to submucosa o T2 - Tumor extension to the muscularis propria or subserosa o T3 - Tumor penetration of the serosa o 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 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

Preferred Examination

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

Case Study: Gastric Carcinoma

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. 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

Case Study: Gastric Carcinoma

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.

Case Study: Gastric Carcinoma

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 int ernal 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. 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 persons chance of developing a disease

1 0

Case Study: Gastric Carcinoma

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

1 1

Case Study: Gastric Carcinoma

PERSONAL DATA
Name: Address: Occupation: Religion: Nationality: Patient X Masin Norte Candelaria, Quezon none Iglesia ni Cristo Filipino

DEMOGRAPHIC DATA
Date of Birth: Place of Birth: Age: Gender: Civil Status: May 6, 1954 Candelaria, Quezon 55 years old Female Married

PATIENT PROFILE
Date Admitted: Attending Physician: Room: Hospital Record No: ER No: February 28, 2010 3:00 pm Dr. Leonardo Holguin Female Surgical Ward 3 A-03317 E-05380

1 2

Case Study: Gastric Carcinoma

HOME ENVIRONMENT Physical Environment: Living with her husband and 2 children

SLEEP AND REST PATTERN Usual Sleep Pattern: Usually sleeps at 9 oclock in the evening and awakes at 5 oclock 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) PAST HEALTH HISTORY Past Medical History She has no history of previous confinement, surgery or another chronic illness. Medications

1 3 Paracetamol (Biogesic) Robitusin Mefenamic Acid Allergies No known allergies to food and drugs Family History Hypertension(Father)

Case Study: Gastric Carcinoma

HISTORY OF PRESENT ILLNESS Reason for seeking medical care: Loss of Appetite Weight 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

1 4

Case Study: Gastric Carcinoma

PHYSICAL EXAMINATION

1 5

Case Study: Gastric Carcinoma

Vital Signs Temperature Pulse Respiration Blood Pressure Upon Admission 36.5C 90beats/min 25breaths/min 110/90mmHg Latest 36.5C 76beats/min 23breaths/min 110/80mmHg

HEAD Skull and Face Rounded, normocephalic and symmetrical Uniform consistency; absence of nodules or masses Symmetric facial movements No tenderness Can move facial muscles at will SCALP SKIN
The skin color is pale

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

No skin abrasions or lesions No edema present Dry skin Temperature is within normal range

1 6 HAIR Evenly distributed hair Black Variable amount of body hair NAILS Convex curvature Smooth in texture Pale With capillary refill of 1-2 seconds

Case Study: Gastric Carcinoma

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 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

1 7 Nasal septum intact and in midline

Case Study: Gastric Carcinoma

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 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

1 8

Case Study: Gastric Carcinoma

Laboratory Examinations

1 9

Case Study: Gastric Carcinoma

CT Scan
Case no: 10-0047 Abdomen: 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.

Impression:
Thickened Gastric Wall Primary consideration is Gastric Lymphoma Suggest Endoscopy

Radiology
Suspicious infiltrates in right upper lung fields, normal heart shadow

Impression:
Suggest Lordotic View

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

Blood Chemistry

2 0

Case Study: Gastric Carcinoma

RBS PPBS Creatinine Sodium Potassium

Result 148 131 0.5 142.3 3.31

Normal values 70-110mg/dl <140 0.5-1.7 135-148mol/L 3.5-5.3mmol/L

Interpretation Increased: hyperglycemia Normal Within normal range Within normal range Decreased:
hyperparathyroidism,vit. D deficiency,GI losses

Miscellaneous Prothrombin Time

Pts PT INR %Activity Result 14 secs 1.2 72.3% Normal values 10-14 0.8-1.3 70-100% Interpretation Within normal range Within normal range Within normal range

Urinalysis
Color Transparency Result Normal values Dark yellow Yellow Turbid Clear Interpretation
Concentrated,sometimes due to some drugs
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 Sp.Gravity Albumin Sugar Pus cells RBC

6.0 1.030 Trace (-) 1-3 1-3

4.8-7.8 1.015-1.025 (-) (-) 0-2/hpf 0-1/hpf

Normal Increased:dehydration
may result from excessive muscular exertion, convulsions, or excess protein ingestion,kidney disease

Normal Increased: sign of an infection or

inflammation in the kidneys, bladder or another area

Increased: glomerular damage,

2 1

Case Study: Gastric Carcinoma

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 Mucus threads Amorphous Urates

Few Plenty few

+,few +,few few

Normal
mucosal surface irritations

Normal

Hematology
WBC Neutrophils Lymphocytes Eosinophils Monocytes HgB Result 5.2 69 28 01 02 11.5 Normal values Interpretation 9/L 5-10x10 Within normal range 55-65 Increased: acute infections,
trauma or surgery, leukemia, malignant disease, necrosis

25-35 Within normal range 1-5 Within normal range 1-6 Within normal range M 13.5Decreased: various anemias, 18.0g/dl pregnancy,severe or prolonged F 12.0-16.0g/dl hemorrhage, and with excessive
fluid intake

Hct Platelet Blood type

0.37 adequate A positive

M 0.400.48g/dl F 0.37-0.45g/dl 150-400x109/L ---------

Within normal range Normal

Others
MCV Result 65.6 Normal values 80.0-99.9fi Interpretation Decreased: RBCs are

2 2

Case Study: Gastric Carcinoma

smaller than normal (microcytic) as is seen in iron deficiency anemia or thalassemia s Decreased: microcytic red cells 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

MCH MCHC

20.3 30.9

27.0-31.0pg 33.0-37.0g/dl

Anatomy

2 3

Case Study: Gastric Carcinoma

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.

2 4

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

2 5

Case Study: Gastric Carcinoma

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

2 6
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

Case Study: Gastric Carcinoma

resembles heavy cream and is called chime. The chime enters the small intestine through the pyloric sphincters. Small Intestine The small intestine is the bodys 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 2.57m (8-18 feet) in a living person.

2 7

Case Study: Gastric Carcinoma

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 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

2 8
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

Case Study: Gastric Carcinoma

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 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

2 9

Case Study: Gastric Carcinoma

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 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 bodys 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. Gallbladder The 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

3 0

Case Study: Gastric Carcinoma

PATHOPHYSIOLOGY

3 1

Case Study: Gastric Carcinoma

3 2

Case Study: Gastric Carcinoma

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

Helicobacter Pylori Infection

Non-Modifiable Factors: Age Blood type

Renders the mucosa more vulnerable to acid damage by disrupting mucous layer, liberating enzymes and toxins&adhering to gastric epithelium

upsets gastric acid secretory physiology to varying degrees

Altered Gastric Secretion

Development of Gastric Ulcers and tissue injury

Cellular Mutation

Persistent Immune Stimulation of Gastric lymphoid tissue

Gastric Lymphoma

3 3

Case Study: Gastric Carcinoma

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.

3 4

Case Study: Gastric Carcinoma

Preventive Management and Treatment

Prevention:

3 5 Screening Programs

Case Study: Gastric Carcinoma

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.

Vaccination
Vaccine 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 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

3 6

Case Study: Gastric Carcinoma

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: 5FU (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 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.

3 7

Case Study: Gastric Carcinoma

Specific Treatment for Gastric Lymphoma Lymphomas of the stomach are primarily treated with CHOP with or without rituximab being a usual first choice. with chemotherapy

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.

3 8

Case Study: Gastric Carcinoma

Health Teaching

3 9

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

4 0

Case Study: Gastric Carcinoma

Nursing Care Plan

4 1

Case Study: Gastric Carcinoma

4 2
ASSESSMENT 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 DIAGNOSIS Imbalanced Nutrition: less than body requirements r/t dysphagia and surgical procedure secondary to gastric carcinoma

Case Study: Gastric Carcinoma

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

INTERVENTION ACTION RATIONALE After the medical Provides the Assess and nursing opportunity to nutritional management, the observe status patient will be able deviations from continually, to acquire adequate normal patient during daily nutrition baseline, and nursing care, noting energy influences choice of interventions. level; condition of skin, nails, hair, oral cavity Establishes Weigh daily baseline, aids in monitoring effectiveness of therapeutic regimen, and alerts nurse to inappropriate trends in weight loss/gain. Identifies Document imbalance parenteral between intake and estimated calorie counts nutritional as appropriate requirements and actual

PLANNING

4 3

Case Study: Gastric Carcinoma

intake. 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/reduce s calorie needs.

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

Vitamins are given for identified

4 4

Case Study: Gastric Carcinoma

indicated(vita min K) deficiencies. EVALUATION At the end of the nursing intervention, the patient will show no signs of infections/complicat ions as evidenced by normal vital signs.

ASSESSMENT Subjective: Nanghihina pa rin ako as verbalized. Objective: Weak in appearance Thin extremities Frequently asleep Poor muscle tone

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

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

INTERVENTION ACTION RATIONALE

Stress/model proper handwashing technique. Maintain sterile technique for invasive procedures. Provide routine site/wound and perineal care Encourage frequent position changes Reduces risk of crosscontamination 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

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

4 5

Case Study: Gastric Carcinoma

infectious process unless patients immune system is too compromised to respond.

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

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.

4 6

Case Study: Gastric Carcinoma

4 7

Case Study: Gastric Carcinoma

Drug Study

4 8

Case Study: Gastric Carcinoma VITAMIN K

Phytonadione

Classification Vitamin/ Supplement

Dosage 1amp IVP then q6x3dos es

Mode Of Action Promotes hepatic synthesis of active prothrombin, proconvertin, plasma thromboplast in component, and Stuart factor

Indication Hypoprothrom binemia caused by anticoagulant therapy Hypoprothrom binemia secondary to other causes

Contraindication Contraindicated in hypersensitivity to drug or its components. (Life-threatening reactions resembling hypersensitivity or anaphylaxis have occurred during and immediately after I.V. injection.) Use cautiously in pregnant or breastfeeding patients, children, and neonates (if product contains benzyl alcohol). Avoid P.O. use in disorders that may prevent adequate

Adverse Effects Hyperbilirubinemia (in infants); with parenteral administration pain, swelling, tenderness at injection site; itchy rash after repeated injections; transient flushing sensations; peculiar taste; anaphylactoid reactions

Nursing Responsibility . >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.

4 9

Case Study: Gastric Carcinoma

absorption.

PARACETAMOL
Acetaminophen Classification Analgesic, antipyretic Dosage 300mg IV q4PRN ANST(-) Mode Of Action Unclear. Pain relief may result from inhibition of prostaglandin synthesis in CNS, with subsequent blockage of Indication Contraindication Nursing Responsibility Hematologic: Observe for thrombocytopenia, acute toxicity hemolytic and overdose. anemia, Caution neutropenia, parents or other leukopenia, caregivers pancytopenia not to give Hepatic: jaundice, acetaminophen hepatotoxicity to children Metabolic: younger than hypoglycemic coma age 2 without Adverse Effects

Mild to Hypersensitivity moderate pain to drug caused by headache,mus cle ache, backache, minor arthritis, common cold, toothache, or menstrual

5 0

Case Study: Gastric Carcinoma

Skin: rash, urticaria Other: hypersensitivity reactions (such as fever) consulting prescriber first. Tell patient, parents, or other caregivers not to use drug concurrently with other acetaminophencontaining products. Advise patient, parents, or other caregivers to contact prescriber if fever or other 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

pain cramps or impulses. fever Fever reduction may result from vasodilation and increased peripheral blood flow in hypothalamus , which dissipates heat and lowers body temperature.

5 1

Case Study: Gastric Carcinoma

significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and behaviors mentioned above.

KETOROLAC
Ketorolac Tromethamine Classification Dosage Mode Of Action Indication Contraindication Adverse Effects Nursing Responsibility

5 2
Nonsteroidal antiinflammatory drug (NSAID, 30mg SIVP q6ANST (-) Interferes with prostaglandi n biosynthesis by inhibiting cyclooxygen ase pathway of arachidonic acid metabolism; also acts as potent inhibitor of platelet aggregation

Case Study: Gastric Carcinoma

Moderately severe acute pain Ocular itching caused by seasonal Postoperative ocular inflammation related to cataract extraction To reduce ocular pain, burning, or stinging after corneal refractive surgery

Hypersensitivity to drug, its components, aspirin, or other NSAIDs Concurrent use of aspirin, other NSAIDs, or probenecid Peptic ulcer disease GI bleeding or perforation Advanced renal impairment, risk of renal failure Increased risk of bleeding, suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis Prophylactic use before major surgery, intraoperative use when hemostasis is critical

CNS: drowsiness, headache, dizziness CV: hypertension EENT: tinnitus GI: nausea, vomiting, diarrhea, constipation, flatulence, dyspepsia, epigastric pain, stomatitis Hematologic: thrombocytopenia Skin: rash, pruritus, diaphoresis Other: excessive thirst, edema, injection site pain

Be aware that oral therapy is indicated only as continuation of parenteral therapy. Know that parenteral therapy shouldnt exceed 20 doses in 5 days. For I.V. use, dilute with normal saline solution, dextrose 5% in water, dextrose 5% and normal saline solution, Ringers solution, or lactated Ringers solution. Administer single I.V. bolus over 1 to 2 minutes. Inject I.M. dose slowly and deeply. Dont give by epidural or

5 3

Case Study: Gastric Carcinoma

Labor and delivery Breastfeeding intrathecal injection. Monitor for adverse reactions, especially prolonged bleeding time and CNS reactions. Check I.M. injection site for hematoma and bleeding. Monitor fluid intake and output.

CEFUROXIME
Cefuroxime Axetil

5 4
Mode Of Action Interferes with bacterial cell-wall synthesis and division by binding to cell wall, causing cell to die. Active against gramnegative and grampositive bacteria, with expanded activity against gramnegative bacteria. Exhibits minimal immunosupp ressant activity.

Case Study: Gastric Carcinoma

Classification Second generation cephalosporin

Dosage 750mg SIVP q8 ANST (-)

Indication Moderate to severe infections, including those of skin, bone, joints, urinary or respiratory tract, gynecologic infections Gonorrhea Bacterial meningitis Otitis media Pharyngitis; tonsillitis

Contraindication Hypersensitivity to cephalosporins or penicillins Carnitine deficiency

Adverse Effects CNS: headache, hyperactivity, hypertonia, seizures GI: nausea, vomiting, diarrhea, abdominal pain, dyspepsia, pseudomembrano us colitis GU: hematuria, vaginal candidiasis, renal dysfunction, acute renal failure Hematologic: hemolytic anemia, aplastic anemia, hemorrhage Hepatic: hepatic dysfunction Metabolic: hyperglycemia Skin: toxic epidermal necrolysis, erythema multiforme, Stevens-Johnson

Nursing Responsibility . Reconstitute drug in vial with sterile water for injection. Give by direct I.V. injection over 3 to 5 minutes into large vein or flowing I.V. line. For intermittent I.V. infusion, reconstitute drug with 100 ml of dextrose 5% in water or normal saline solution; administer over 15 minutes to 1 hour. For continuous infusion, give in 500 to 1,000 ml of compatible solution; infuse over 6 to 24

5 5

Case Study: Gastric Carcinoma

syndrome Other: allergic reaction, drug fever, superinfection, anaphylaxis hours. Inject I.M. doses deep into large muscle mass. Give oral form with food. Be aware that tablets and oral suspension are exchangeable on a milligramfor-milligram basis.

5 6

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 Nursing Tenth Edition Suzanne C. Smeltler, Brenda G. Bare Essentials of Anatomy and Physiology 8th Edition Elaine Marieb

Eternal Links:
www.nlm.nih.gov/medlineplus/ency/article/000223.htm en.wikipedia.org/wiki/Stomach_cancer emedicine.medscape.com/article/375384-overview www.google.com

Others:
Patients Chart