Stomach and Duodenum Diseases / Stomach Cancer

Gastric cancer (stomach cancer) is cancer that occurs in the stomach and is, according to international statistics, the third most common cause of cancer death in the world.
There are several factors that increase a person’s risk of developing gastric cancer (stomach cancer), such as:

Gastric cancer (stomach cancer) can give you the following symptoms and signs:

If you have the above symptoms, the following tests and procedures are necessary to diagnose stomach cancer(gastric cancer):

– Upper endoscopy with biopsy – the most common investigation used in the diagnosis of gastric cancer; it involves inserting a thin tube (the diameter of a pen) through the oral cavity into the stomach, with a camera at the end, which allows the examining physician to visualize the inside of the stomach and to harvest a fragment of tissue from the suspicious-looking area of the stomach, which is then analyzed under a microscope
– Imaging tests – computed tomography (CT) – takes a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region, contrast substance is used
– Blood tests – haemoleucogram (red blood cell count, white blood cell count, platelet count, haemoglobin-oxygen carrying protein) and blood biochemistry

To determine the extent of gastric cancer (stomach cancer) / stage of the disease, it is necessary to perform additional investigations such as:

– Assay of serological tumour markers – hCG (human chorionic gonadotropin), CA-125, CAE (carcinoembryonic antigen)
– Chest radiography of the organs and bones of the chest
– Endoscopic ultrasonography – an investigation that combines endoscopy with ultrasonography, assessing the degree of infiltration (invasion from the tumour) of the gastric wall and surrounding organs
– Computed Tomography (CT) – a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region the contrast substance is used; and Positron Emission Tomography (PET) – a modern method that allows a complete examination of the body
– Diagnostic laparoscopy – minimally invasive exploration method – through a surgical incision (cut) in the abdominal wall, a tube (laparoscope) is introduced into the abdomen allowing direct visualization of the intra-abdominal organs and through another surgical incision, an instrument is introduced allowing the collection of samples (tissue biopsy or intra-abdominal fluid aspiration)

Depending on the stage of your cancer and the clinical condition you have, there are several treatment options, such as surgical treatment and/or cancer treatment

Involves partial (subtotal gastrectomy) or total (total gastrectomy) removal of the stomach depending on the location of the tumour formation, plus removal of the affected lymph nodes (lymphadenectomy)

Anti-tumour treatment, which uses certain drugs to destroy cancer cells; it can be administered before surgical treatment (neoadjuvant chemotherapy) with the aim of reducing the size of the tumour formation so that it can subsequently be surgically removed, or it can be administered after surgical treatment (adjuvant chemotherapy) with the aim of destroying cancer cells that may have already spread in the body; chemotherapy can also be used as the only treatment for gastric cancer in advanced stages to relieve symptoms.

Anti-tumour treatment, which uses high-intensity X-rays or other types of radiation that are capable of destroying malignant cells; it can be as in the case of chemotherapy of two types: neoadjuvant or adjuvant

It involves combining chemotherapy with radiotherapy to increase their effectiveness.

It uses substances produced by the body or synthesised in the laboratory to strengthen the immune system in its fight against cancer.

It represents the migration of a portion of the stomach from the abdominal cavity into the thoracic cavity through the diaphragmatic orifice. The exact causes of hiatal hernia are not known. In some cases, following injury or trauma the muscle tissue may weaken, leading to the stomach being pushed through the diaphragmatic muscle.

Another cause may be repeated intense pressure on the muscles around the stomach (through coughing, vomiting, difficulty in passing stools, lifting heavy objects). It may also be caused by a congenital abnormality of the diaphragmatic muscle (congenital hiatal hernia).

Factors that increase the risk of developing a hiatal hernia are: obesity, smoking and old age.

There are several types of hiatal hernias:

Most patients with hiatal hernia have no symptoms, or minor, non-specific symptoms. If you are experiencing symptoms due to a hiatal hernia, they may be:

In order to establish the exact diagnosis of hiatal hernia, certain investigations need to be carried out:

– Barium transitus – a special type of X-ray that involves swallowing a suspension of barium, which will allow radiological visualization of the stomach and highlight the elevation of the stomach above the diaphragmatic muscle
– Upper digestive endoscopy – involves inserting a thin tube (the diameter of a pen) through the oral cavity to the stomach, with a camera at the end, which allows the examining physician to visualize the stomach hernia. It is indicated when the symptoms are not specific and the transit is not conclusive.
– Blood tests – haemoleucogram (red blood cell count, white blood cell count, platelet count, haemoglobin-oxygen carrying protein) and blood biochemistry

In most cases of hiatal hernia there is no need for treatment. If you have symptoms, depending on their severity, conservative treatment may be instituted (antacid drugs, H2-receptor blockers or proton pump inhibitors – to reduce acid production in the stomach if acid reflux is present).

If symptoms persist, surgical treatment is indicated.
Surgical treatment is also indicated if you have esophageal ulceration, esophagitis, Barett’s esophagus (precancerous changes in the cells of the esophagus), signs of obstruction, stricture or perforation (when surgical treatment is performed as an emergency).

Surgical treatment (operative cure of hiatal hernia) involves repositioning the herniated organs in the abdominal cavity, resection of the hernia sac, recalibration of the diaphragmatic orifice (esophageal hiatus) and creation of an antireflux procedure (fundoplication)

Gastrointestinal stromal tumours (GISTs) are mesenchymal tumours of the gastrointestinal tract that arise from a particular type of cell (interstitial cells of Cajal).

Symptomatology is given according to the size and location of the tumour. Thus, you can accuse:

– Abdominal discomfort or pain (epigastric – upper abdominal region)
– Asthenia (due to anaemia caused by bleeding from the tumour)

The diagnosis of GIST is frequently established incidentally during routine examinations. Investigations used in making the diagnosis can be:

– Upper digestive endoscopy – involves inserting a thin tube (diameter of a pen) through the oral cavity into the stomach, with a camera at the end, which allows the examining physician to visualize a submucosal tumor formation protruding into the stomach.
– Echoendoscopy – method that combines ultrasound with endoscopy, and allows visualization of the tumor formation and determination of its belonging to the gastric wall, submucosal
– Computed tomography (CT) scan – takes a series of detailed images of specific areas of the body, these images are taken from different planes. It is indicated if the above examinations cannot establish the diagnosis (if it cannot be established which organ the tumour formation belongs to)
– Laboratory tests – haemolucogram – which can detect anaemic syndrome
Morphological and immunohistochemical tests (CD34 and CD117 protein detection, cKIT or PDGFRA mutations) are required to establish a pathological diagnosis of GIST.

All GISTs require surgical treatment. Depending on their location and size, a limited resection or removal of a portion of the stomach (subtotal gastrectomy) may be chosen. If the tumour is larger than 10 cm and cannot be resected (locally advanced or metastatic tumours – spread to other organs), an oncological consultation is necessary in order to initiate neoadjuvant chemotherapy treatment (anti-tumour treatment, which uses certain drugs to destroy cancer cells, given before surgical treatment).

Benign tumours are non-cancerous tumours that remain in one place and do not spread to other parts of the body. Also after they are removed they do not reappear. Even if they are not cancerous, they can cause symptoms by putting pressure on surrounding structures. Pre-cancerous (pre-malignant) tumours are benign tumours containing abnormal cells that have the potential to turn into cancer if left untreated.
In contrast, malignant tumors are cancerous tumors that develop in nearby tissues, contain cells that can rupture and reach the blood or lymphatic system, thus spreading to lymph nodes and other distant regions of the body.

In the case of duodenal tumours, they are often asymptomatic if small. You may experience non-specific symptoms such as pain, discomfort, bloating in the upper abdominal area. In the case of ulcerative tumours, you may experience asthenia (fatigue) due to an anaemic syndrome caused by chronic or acute blood loss.

Larger tumours that are infiltrative-stenotic (leading to narrowing of the duodenum lumen) can lead to gastric evacuatory insufficiency syndrome (delay in stomach emptying) manifested by food vomiting, bloating, pain, early satiety.

If the tumour is located in the area where the bile discharges from the main bile duct into the duodenum (the ampullary area), you may have yellowing of the skin and whites of the eyes (sclerosing jaundice).

– Abdominal discomfort or pain (epigastric – upper abdominal region)
– Asthenia (due to anaemia caused by bleeding from the tumour)

In order to accurately determine the diagnosis of duodenal tumour it is necessary to carry out certain investigations:

– Upper digestive endoscopy with biopsy – involves inserting a thin tube (diameter of a pen) through the oral cavity into the duodenum, with a camera at the end, which allows the examining physician to visualize the tumor and collect a fragment of tissue from the suspicious-looking area of the duodenum, which is then analyzed under a microscope.
– Laboratory tests – haemolucogram – (which may show an anaemic syndrome) and biochemistry which may indicate iron depletion (iron deficiency anaemia, in case of chronic or acute bleeding)

In the case of benign duodenal tumours (diagnosis of certainty by biopsy), depending on their size and location, surgical treatment is required, i.e. removal of a limited portion of the duodenum or cephalic duodenopancreatectomy (if the tumour is large and located in the second portion of the D2 duodenum), which involves removal of the duodenum, the first portion of the jejunum, the pancreatic head, the last portion of the stomach, the cholecyst, the last part of the main bile duct leading from the liver to the duodenum, and nearby lymph nodes (lymphadenectomy), followed by subsequent restoration of digestive continuity.

In the case of malignant duodenal tumours, regardless of location or size, surgical treatment is indicated, cephalic duodenopancreatectomy. If the tumour cannot be removed (invasion of important structures such as the arteries, hepatic artery, mesenteric artery, aorta or inferior vena cava, or if the disease has spread to other organs – metastases), a bypass / digestive bypass (bypassing the duodenal tumour by creating an alternative route to ensure digestive transit) can be created.

Aorto-measenteric pylorus is a rare form of obstruction in the digestive tract, specifically in the third portion of the duodenum, which is compressed due to narrowing of the space between two vascular structures located at this level (aorta and superior mesenteric artery originating from the aorta). This narrowing is mainly caused by a decrease in the quantity of adjacent lymphatic and adipose tissues, resulting in a decrease in the angle between the two vascular structures, which varies between 38 and 65º. In the case of aorto-measenteric clamp this angle can be reduced to 6º.

The symptoms are characteristic of a high obstruction. Thus, you can charge according to the degree of obstruction:

– Mild to moderate obstruction: postprandial upper abdominal pain (epigastric pain), early satiety.
– Severe obstruction: intense nausea, green (bilious) vomiting, weight loss

The following investigations may be performed to establish the diagnosis of aorto-measenteric clamp:
– Abdominal X-ray on the nude – radiological examination that may show distension of the stomach and dilatation of the first portions of the duodenum
– Barium transit – a special type of X-ray that involves swallowing a barium suspension, which will show prolonged retention of the swallowed suspension in the stomach and the first portion of the duodenum, with slow evacuation to the small intestine
– Abdominal ultrasound – non-invasive and atraumatic imaging method based on ultrasound, which allows the measurement of the angle between the aorta and the superior mesenteric artery and the identification of other abnormalities in the vicinity (aorto mesenteric angle below 25º)
– Echo-endoscopy – a method that combines ultrasound with endoscopy, with which it is also possible to measure the aorto-mesenteric angle and visualise adjacent changes
– Arteriography – a radiological examination that can visualize vascular structures by injecting a contrast substance (it is usually associated with a barium transit)
– Angio-CT/ angio-MRI – state-of-the-art, non-invasive imaging method that combines computer technology with angiography and is used to evaluate arteries; can reveal abnormalities of the superior mesenteric artery
– Laboratory tests – haemolucogram – (may show an anaemic syndrome) + biochemistry which may indicate electrolyte imbalances (dyselectrolytes – low potassium, sodium, chloride values), dehydration syndrome (elevated serum creatinine and urea values)

Conservative treatment
Hydro-electrolytic and acid-base rebalancing, nasogastric decompression (insertion of a tube through the nose to the stomach to evacuate the stomach), nutritional support, administration of drugs to stimulate motility (prokinetics).

Surgical treatment
Indicated in severe or chronic occlusive syndrome with malnutrition and no longer responding to conservative treatment; involves anterior transposition of the third portion of the duodenum, sectioning of the suspensory ligament of the duodenum (Treitz’s ligament) + intestinal bypass (Strong’s operation); another surgical option is the creation of a digestive bypass by bypassing the obstructed portion of the duodenum (duodeno-jejunal/ gastro-jejunal bypass).