NCLEX Review Guide: Gastric Cancer

Understanding Gastric Cancer

• Gastric adenocarcinoma accounts for 95% of all stomach cancers and typically develops in the mucosa before spreading to deeper layers.
• Helicobacter pylori infection is the strongest risk factor, causing chronic inflammation that leads to intestinal metaplasia and dysplasia.
• Other significant risk factors include chronic atrophic gastritis, pernicious anemia, family history, and dietary factors like high salt intake and processed foods.

Signs and Symptoms

• Early satiety and persistent epigastric pain are hallmark symptoms that worsen with eating and may radiate to the back.
• Progressive symptoms include unexplained weight loss, nausea, vomiting (especially if coffee-ground appearance), and dysphagia.
• Virchow's node (enlarged left supraclavicular lymph node) and Sister Mary Joseph nodule (periumbilical metastasis) indicate advanced disease.

Diagnostic Workup

• Upper endoscopy with biopsy is the gold standard for diagnosis, allowing direct visualization and tissue sampling of suspicious lesions.
• CT scan of chest, abdomen, and pelvis evaluates for metastatic disease, while endoscopic ultrasound (EUS) determines depth of invasion and regional lymph node involvement.
• Laboratory studies include CBC (anemia), comprehensive metabolic panel, liver function tests, and tumor markers like CEA and CA 19-9.

Surgical Interventions

1. Subtotal gastrectomy removes the distal portion of stomach with reconstruction via Billroth I or II procedure.
2. Total gastrectomy removes entire stomach with esophagojejunostomy reconstruction for proximal tumors or extensive disease.
3. Lymph node dissection (D1 or D2) is performed based on tumor location and staging requirements.

Chemotherapy & Radiation

• Neoadjuvant chemotherapy may be used to shrink tumors before surgery, typically using regimens like FOLFOX or ECF.
• Adjuvant chemoradiation is standard for patients with positive margins or lymph node involvement post-surgery.

Immediate Post-Op Priorities

• Monitor for anastomotic leak by assessing for fever, tachycardia, abdominal pain, and drainage from surgical site or drains.
• Maintain nasogastric decompression until bowel function returns, typically 3-5 days post-operatively with return of bowel sounds.
• Assess respiratory status frequently due to high abdominal incision limiting deep breathing and coughing effectiveness.

Nutritional Management

• Dumping syndrome prevention requires teaching patients to eat small, frequent meals, avoid liquids with meals, and lie down after eating.
• Vitamin B12 deficiency is inevitable after total gastrectomy due to loss of intrinsic factor production, requiring lifelong monthly injections.
• Iron and folate supplementation may be necessary due to decreased absorption in the remaining GI tract.

Dietary Modifications

• Teach patients to eat 6-8 small meals daily, chewing food thoroughly and eating slowly to prevent dumping syndrome.
• Separate solids and liquids by consuming fluids 30-60 minutes before or after meals to slow gastric emptying.
• Emphasize high-protein, low-carbohydrate foods while avoiding concentrated sweets and dairy products initially.

Long-term Follow-up

• Schedule regular endoscopic surveillance every 6-12 months for early detection of recurrence or complications.
• Monitor nutritional status with periodic labs including B12, folate, iron studies, and complete blood count.
• Report immediately any signs of obstruction, severe nausea/vomiting, or significant weight loss to healthcare provider.