Gastric Neoplasms

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

Gastric neoplasms, commonly referred to as stomach tumours, are abnormal growths that arise in the lining of the stomach. These neoplasms can be either benign or malignant, with the latter being more concerning as it indicates the presence of cancer.

• Helicobacter pylori infection: One of the leading causes of gastric neoplasms is chronic infection by the bacterium Helicobacter pylori. This bacterium colonizes the stomach and causes chronic gastritis. Long-term inflammation and damage to the gastric mucosa increase the risk of developing gastric neoplasms over time.

• Genetic predisposition: Genetic factors play a significant role in the development of gastric neoplasms. Certain inherited genetic mutations, such as mutations in the CDH1 gene, are associated with an increased risk of developing hereditary diffuse gastric cancer. Variations in other genes, including TP53 and BRCA2, have also been identified as potential risk factors for gastric neoplasms.

• Dietary factors: Dietary habits can influence the development of gastric neoplasms. A high consumption of salt, smoked or pickled foods, and processed meats have been linked to an increased risk of gastric cancer. On the other hand, a diet rich in fruits and vegetables, especially cruciferous vegetables, has been associated with a lower risk of developing gastric neoplasms.

• Tobacco and alcohol consumption: Smoking and excessive alcohol consumption have long been recognized as risk factors for various types of cancer, including gastric neoplasms. These harmful habits not only increase the risk of developing cancer but also contribute to the progression and poor prognosis of gastric neoplasms.

• Obesity: Being overweight or obese is becoming an increasingly significant risk factor for gastric neoplasms. Excess body weight, especially around the waist, increases chronic inflammation and insulin resistance, which can promote the growth of cancer cells in the stomach.

• Occupational exposure: Prolonged exposure to certain occupational hazards, such as asbestos and chemicals like benzene, has been associated with an increased risk of gastric neoplasms. These exposures often occur in industries such as manufacturing, construction, and chemical production.

• Age and gender: Gastric neoplasms predominantly affect older individuals, with the risk increasing significantly after the age of 50. Furthermore, men have a higher incidence of gastric neoplasms compared to women, although the reasons behind this gender-based disparity are not yet fully understood.

The development of gastric neoplasms usually begins with a sequence of cellular changes in the gastric mucosa. Chronic inflammation caused by factors such as Helicobacter pylori infection, long-term alcohol consumption, smoking, and dietary factors like high intake of processed meats and low intake of fruits and vegetables contribute to the initiation and progression of this disease.
In the early stages, these cellular changes can result in the formation of precancerous lesions, such as gastric adenomas or gastric dysplasia. Stromal mutations, alterations in oncogenes, and tumor suppressor genes further promote the growth and division of aberrant cells, leading to the formation of gastric tumours.
The development of gastric neoplasms is also influenced by the histological subtype. The two main types include intestinal-type and diffuse-type gastric cancers. Intestinal-type gastric cancer often arises from precancerous gastric lesions, progresses slowly, and is associated with H. pylori infection. Diffuse-type gastric cancer, on the other hand, has a more aggressive growth pattern, lacks a distinct precursor lesion, and tends to occur in younger individuals with a family history of stomach cancer.
Once the tumor has formed, it can invade the deeper layers of the stomach wall. This invasion can lead to the disruption of normal gastric functions. As the tumor continues to grow, it can obstruct the passage of food from the stomach to the small intestine, resulting in symptoms such as dysphagia, early satiety, and unintentional weight loss.
Metastasis is a common feature of advanced gastric neoplasms. Cancer cells can spread through the bloodstream or lymphatic system to regional lymph nodes, liver, lungs, and other distant organs. Metastasis not only leads to a poorer prognosis but also contributes to the manifestation of systemic symptoms, including fatigue, anaemia, and jaundice.
In the later stages, complications such as bleeding from the tumor, perforation of the stomach wall, and gastric outlet obstruction can arise, further exacerbating the morbidity associated with gastric neoplasms.

• Helicobacter pylori Infection: A Culprit
  Helicobacter pylori (H. pylori) infection stands as a critical risk factor for the development of gastric neoplasms. This bacterium colonizes the stomach lining, causing chronic gastritis and peptic ulcers in infected individuals. Over time, chronic inflammation resulting from H. pylori infection may lead to the transformation of healthy gastric cells into cancerous cells.
  Research reveals that H. pylori infection is one of the most common bacterial infections worldwide. The transmission route for this infection primarily involves oral-oral or faecal-oral routes, emphasising the importance of maintaining proper hygiene practices and a clean environment.
  Although not all individuals infected with H. pylori will develop gastric neoplasms, the presence of this bacterium significantly elevates the risk.

• Genetic predisposition.

• Smoking.

• Dietary factors.

1. Persistent Abdominal Discomfort: Patients with gastric neoplasms may experience persistent discomfort or pain in the upper abdomen. This pain may initially be mild and intermittent but can progressively increase in severity and become constant as the tumor grows.
2. Appetite Changes and Weight Loss: Gastric neoplasms can cause a reduced appetite or early satiety, leading to unintended weight loss. The tumour’s presence may interfere with the stomach's ability to store and process food properly, causing a feeling of fullness even after consuming small amounts.
3. Nausea and Vomiting: Alongside appetite changes, individuals with gastric neoplasms may frequently experience nausea, which can lead to occasional bouts of vomiting. These symptoms can be unrelated to food intake and may persist over time.
4. Difficulty Swallowing: As stomach cancer progresses, it can obstruct the passage of food from the oesophagus into the stomach. This can result in dysphagia, or difficulty swallowing, leading to a sensation of food getting stuck in the throat or chest. It may be accompanied by discomfort or pain during swallowing.
5. Gastrointestinal Bleeding: Some patients may notice symptoms of gastrointestinal bleeding, which can manifest as bloody stools or black, tarry stools (melena). Vomiting blood (hematemesis) may also occur in more advanced disease stages, indicating bleeding from the stomach.
6. Fatigue and Weakness: Gastric neoplasms can cause a general feeling of weakness, fatigue, and loss of energy. These symptoms may arise due to the cancer's impact on the body's nutritional status, chronic blood loss, or the release of substances by the tumor that affect energy metabolism.
7. Anaemia: Chronic blood loss from gastric neoplasms can lead to iron deficiency anaemia. This condition might cause symptoms such as weakness, shortness of breath, pale skin, and heart palpitations.
8. Swollen Lymph Nodes: In some cases, the cancerous cells can spread to nearby lymph nodes, causing them to become enlarged. These swollen lymph nodes can typically be felt as painless lumps under the skin around the neck, collarbone, or abdomen.

Physical examination and history:
Detailed medical history, thorough physical examination, and assessment of associated symptoms. PAs should look for warning signs such as unexplained weight loss, abdominal discomfort, dysphagia, loss of appetite, and anaemia, which may prompt further investigations.
Endoscopy:
Upper gastrointestinal endoscopy, considered the gold standard in diagnosing gastric neoplasms, allows direct visualization and evaluation of gastric mucosa. During the procedure, a flexible tube with a camera and a light source is inserted through the mouth and oesophagus, enabling examination of the stomach lining. Endoscopy also allows for the collection of tissue samples for biopsy, which aids in confirming the presence of neoplastic cells.
Biopsy and Histopathology:
Biopsy samples taken during an endoscopy enable histopathological examination, which is essential for establishing the nature of the lesion. Pathologists analyse the tissue under a microscope to determine the presence of cancerous cells, identify the histological type, and grade the tumour’s aggressiveness. This information helps guide treatment decisions and prognosis.
Imaging Studies:
Imaging techniques play a vital role in identifying the extent of tumor involvement and staging. These include:
1. Computed Tomography (CT) Scan: CT scans provide detailed cross-sectional images of the stomach and surrounding structures, helping evaluate tumor size, lymph node involvement, and the presence of distant metastases.
2. Magnetic Resonance Imaging (MRI): MRI may be useful in assessing the location extent of tumours and determining the proximity of neoplasms to vital structures.
3. Positron Emission Tomography (PET) Scan: PET scans help identify areas of increased metabolic activity, aiding in the detection of primary tumours, lymph node involvement, and possible metastases.

Laboratory Tests:
Laboratory investigations assist in assessing the overall health status of the patient and detecting specific markers associated with gastric neoplasms. These include:
1. Full blood count (FBC): FBC helps identify anaemia and other blood cell abnormalities, which may be indicative of gastric cancer.
2. Tumor Markers: Certain tumor markers, such as carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9), are elevated in some cases of gastric neoplasms. While these markers lack diagnostic specificity, they can be valuable in monitoring treatment response and detecting tumor recurrence.
Genetic Testing:
Advancements in molecular biology have led to the identification of specific genetic alterations in gastric neoplasms. Genetic testing may be done to determine the presence of mutations in genes such as HER2 (human epidermal growth factor receptor 2) or microsatellite instability (MSI), which have implications for targeted therapies and prognosis.

1. Referral and diagnosis:
Referral of patients with suspected symptoms to a specialist upper gastrointestinal cancer team for further investigation.
2. Surgical intervention.
3. Palliative care.

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