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Table of Contents
CLINICAL ARTICLE
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 122-128

Care of patient with carcinoma stomach


1 Former Tutor, CMC, Vellore, Tamil Nadu, India
2 Professor, College of Nursing, CMC, Vellore, Tamil Nadu, India
3 Charge Nurse, CMC, Vellore, Tamil Nadu, India

Date of Submission08-Nov-2018
Date of Decision07-Sep-2019
Date of Acceptance09-Sep-2019
Date of Web Publication19-Feb-2021

Correspondence Address:
Mrs. Nirmala Emmanuel
College of Nursing, CMC, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCN.IJCN_128_20

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  Abstract 

Gastric cancer is not caused by just a single factor but a combination of genetic, socio-cultural and environmental factors. Stomach cancer can have no outward signs and symptoms in its early stages to varied symptoms in the later stages. The mode of treatment is chosen based on how long one has had the disease or what the stage of the cancer is. After the diagnostic laparoscopy, the patient with the tumor deemed resectable undergoes gastrectomy, if deemed unresectable then undergoes chemotherapy. This paper outlines the nursing care of a patient Stomach cancer.

Keywords: Stomach cancer, symptoms, environmental factors, treatment


How to cite this article:
Johnson N, Emmanuel N, Grace S, Kalaivanan J. Care of patient with carcinoma stomach. Indian J Cont Nsg Edn 2020;21:122-8

How to cite this URL:
Johnson N, Emmanuel N, Grace S, Kalaivanan J. Care of patient with carcinoma stomach. Indian J Cont Nsg Edn [serial online] 2020 [cited 2021 Jun 23];21:122-8. Available from: https://www.ijcne.org/text.asp?2020/21/2/122/309846


  Introduction Top


Stomach cancer, also known as gastric cancer, is the development of cancer cells from the inner lining of the stomach, often growing into a tumour over the years. According to statistics, cancer of the stomach is more common amongst men than amongst women, both in Asia (second most common amongst men and third most amongst women) and India (fifth most common amongst men and seventh most common amongst women). Older adults of average age 70 are found to be more at risk. The fact that it is the second most common cause of cancer death worldwide explains the fatality of the disease and explains the urgent need for improvement in its treatment and therapeutic methods. Its rate of 5-year prognosis in developed and developing countries is as low as 30% and 20%, respectively, and it is because the symptoms are vague and are mistaken for less serious conditions, thereby reporting the cancer only in its advanced stages.[1]

The incidence of the cancer in India is less when compared to other countries worldwide. A marked geographical distinction is observed by the fact that southern men are more affected than northerners, and the difference in diet is found to be the reason. The common knowledge that alcohol, tobacco and use of very spicy and steaming hot food are the prominent risk factors of the said cancer is proven by case–control studies carried out in Trivandrum and Hyderabad. Mizoram is the state with highest incidence rate where 30% of all the reported cancer cases are gastric [Figure 1].[2]
Figure 1: Structure and functions of the stomach

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Structure and functions of the stomach

The stomach, situated between the oesophagus and small intestine, is a hollow muscular organ which stores food while eating, secretes digestive fluids and propels the chyme (partially digested food) into the small intestine. It is divided into four regions: the cardia, fundus, body and pylorus. The stomach secretes mucus, which protects the epithelium from chemical insult. Hormone gastrin controls acid secretion such as hydrochloric acid and pepsinogen, which are in turn secreted by parietal cells and chief cells.[3]

The arterial supply to the stomach comes from the caeliac trunk and its branches. It consists of left and right gastric artery, left and right gastroepiploic artery and short gastric artery, which arises from the splenic artery. The venous drainage runs parallel to the arteries and is compiled of left and right gastric vein, left and right gastroepiploic vein and short gastric veins, which ultimately drain into superior mesenteric vein. Stomach also receives innervations from caeliac ganglia and vagus nerve of autonomous nervous system and caeliac lymph nodes make up the lymph drainage.[3]

Aetiology of cancer stomach

Gastric cancer is not caused by just a single factor but a combination of genetic, sociocultural and environmental factors. The following are the most common aetiological factors involved.[4],[5],[6]

  • Helicobacter pylori infection: It is the strongest known risk of stomach cancer. Helicobacter pylori, a spiral-shaped bacterium that grows in the mucus layer of the stomach, is said to affect 50% of the world's population, but it developing into cancer is <5%. Because H. pylori effectuate the greatest amount of inflammation, it is considered that only a particular strain of the bacterium causes malignancy. Studies show that treatment for infection of H. pylori with antibiotics reduces the incidence of gastric cancer[7]
  • Alcohol: Ethanol in alcohol is the substance which causes cancer. It produces a known carcinogen called acetaldehyde, and the cells damaged by alcohol try to repair themselves and cause DNA changes, thereby resulting in cancer. The amount of alcohol one consumes overtime is the most important factor in raising cancer risk.[8] Furthermore, it adversely aids other harmful chemicals such as tobacco smoke to penetrate the cells of the digestive system
  • Smoking: An estimated 11% of stomach cancer cases are due to smoking. Both the number of cigarettes used and the duration of smoking directly affect cancer risk[9]
  • Diet: The salt content in the food is a major impetus to gastric cancer. Therefore, pickled foods and cured or processed meats are the most harmful. Intake of comparatively few fruits and vegetables create an imbalanced diet to make for a serious contribution. Obesity also is said to increase the risk[10]
  • Previous gastric surgery: Surgeries to treat non-cancerous diseases such as stomach ulcers, surgery on any body part (e.g., vagus nerve) which affects the stomach and partial gastrectomy are causative of stomach cancer, although it usually only evolves gradually. It results in reduced production of acid and promotes the growth of nitrite-producing bacteria. The reflux of bile from small intestine into the stomach after surgery also lead to cancer
  • Pernicious anaemia: Pernicious anaemia, atrophic gastritis and stomach cancer are directly related and are risk factors of each other[7]
  • Adenomatous polyps: Even though most polyps are not a risk for stomach cancer, adenomatous, also known as adenomas can result in cancer
  • Chronic atrophic gastritis: Risk of developing gastric cancer increases six times for patients with prolonged case of gastritis
  • Radiation exposure: Strong evidence is recorded of a connection between stomach cancer and exposure to ionising radiation from a research carried out amongst nuclear field workers in North America
  • Genetic factors: Around 10% of all stomach cancer cases are found to be genetic in origin. Those who have a gene variant rs1230025, even though they are not drinkers or smokers, have high risk of gastric cancer. Familial adenomatous polyposis caused by mutations in the APC gene, is also causative. Other hereditary syndromes which lead to stomach cancer are hereditary non-polyposis colorectal cancer, Li–Fraumeni Syndrome and Peutz–Jeghers Syndrome.[7]


Pathophysiology

Pathologically speaking, stomach cancer is the abnormal proliferation of the cells of the inner lining of the gastric mucosa. The tumour infiltrates the surrounding mucosa, penetrating the wall of the stomach and adjacent structures. The liver, pancreas, oesophagus and duodenum are often affected and metastasis to the peritoneal cavity occurs in the later stages of the disease. The types include:

  • Adenocarcinomas develop within the cells of the innermost lining of the stomach, mucosa (about 90%–95%)
  • Lymphoma is a cancer of the lymph tissues of the stomach (1%–5%), e.g., Non-Hodgkin lymphoma
  • Gastrointestinal (GI) stromal tumours, or GISTs, are a rare type of stomach cancer that arises from the interstitial cells of Cajal - (2%)
  • Carcinoid tumorsarise from the secretory cells of the stomach and usually do not metastasise (1%)
  • Other types of cancer, such as squamous cell carcinoma, small cell carcinoma, neuroendocrine tumours and leiomyosarcoma, can also start in the stomach, but these cancers are very rare [Figure 2].[11]
Figure 2: Pathophysiology

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Clinical manifestations

Stomach cancer can have no outward signs and symptoms in its early stages, which make it hard to diagnose. Moreover, the symptoms of later stages of cancer are often mistaken for other minor diseases including:[12],[13]

  • Lack of appetite
  • Early satiety
  • Frequent heartburn
  • Abdominal pain which worsens after eating
  • Nausea and vomiting, with or without blood
  • Sudden weight loss
  • Melena and anaemia
  • Excessive fatigue
  • Jaundice and ascites.


Diagnostic tests

The diagnosis of cancer stomach is identified and confirmed by the tests given in [Table 1] and [Table 2].[14],[15]
Table 1: Diagnostic tests for cancer stomach and its indication

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Table 2: T-staging of gastric cancer, American Joint Committee on Cancer 7th manual

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Staging

Management

The mode of treatment is chosen based on how long one has had the disease or what the stage of the cancer is. After the diagnostic laparoscopy, the patient with the tumour deemed resectable undergoes gastrectomy, if deemed unresectable then undergoes chemotherapy.[15]

Surgery

Surgery is the most effective treatment for stomach cancer, and it is adequate only with a tumour-free resection margin of at least 4 cm. Palliative procedures such as gastric or oesophageal bypass, gastrostomy or jejunostomy may temporarily alleviate symptoms of nausea and vomiting, and it is also preferred when there is metastasis to vital organs such as liver so that it will give a better quality of life.[12],[16]

Total gastrectomy is performed for a resectable cancer in the body of the stomach. The entire stomach along with duodenum, lower portion of oesophagus and lymph nodes with supporting mesentery is removed. Reconstruction is done with Rox-En-Y oesophagojejunostomy or gastrojejunostomy.

  • Proximal subtotal gastrectomy may be performed for a resectable tumour in the proximal portion or cardia but a total or oesophagogastrectomy is better for extensive resection [Figure 3].
Figure 3: Gastrectomy

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Radical subtotal gastrectomy is preferred for middle and distal tumours. Billroth 1 is where the lower portion of the antrum as well as a portion of duodenum is removed, and the remaining segment is anastomosed to the duodenum. Billroth 2, on the other hand, is done for anastomosis with the jejunum while the duodenal stump remains.

Chemotherapy

Chemotherapy is also an important mode of treatment for gastric cancer. It can be given before surgery to shrink the tumour and obtain better results and to prevent the cancer from recurring. This is known as neoadjuvant chemotherapy (NACT). Chemotherapy given after surgery is called adjuvant chemotherapy. This helps kill any remaining cancer cells. Chemotherapy given along with radiation is called chemoradiation. Chemotherapy is also given to patients with severely metastasised cancer as a palliative option.

The commonly used chemotherapy drugs are cisplatinum, 5-flurouracil, capecitabine, paclitaxel, epirubicin, docetaxel, oxaliplatin and irinotecan and cisplatin, doxorubicin, etoposide and mitomycim-C. Mainly 5-FU-based combination therapy is used for improved response (Cancer Treatment Centers of America, 2018).

Radiation therapy

Radiation therapy targets a specific part and kills the cancer cells using high-energy rays. It can be given along with chemo (chemoradiation), as mentioned earlier, and also after surgery to eliminate the very small remnants. In advanced stage cancer, it helps slow the growth and ease the symptoms in patients with obstruction, GI bleeding and significant pain. External beam radiation therapy is most often used to treat stomach cancer.[15],[17]

Targeted therapy

Treatments where cancer-specific genes, proteins or tissue are directly targeted, thus limiting the growth and spread of the disease.

Human epidermal growth factor receptor 2-targeted therapy

Human epidermal growth factor receptor (HER2) is a growth-promoting protein present on the surface of the cancer cells in most stomach cancer cases and is associated with poor prognosis. Trastuzumab, a monoclonal antibody, targets the HER2 protein and is given once every 2 or 3 weeks along with chemotherapy. This is effective on patients who are HER2 positive (increased levels of HER2).

Antiangiogenesis therapy

Angiogenesis is the process of making new blood vessels for a tumour to survive. Ramucirumab (Cyramza), a monoclonal antibody, focusses on stopping it. The drug is administered intravenously every 2 weeks.

Immunotherapy

Immunotherapy helps the patient's own immune system to find and destroy the cancer cells. Pembrolizumab (Keytruda) helps promote immune response against cancer cells by blocking PD-1 protein which keeps T cells of the immune system from attacking other cells of the body. Thereby, it helps shrink the tumour and repress its growth. It is given as intravenous (IV) infusion every 3 weeks.

Nursing management

Nursing management of a patient with cancer stomach is presented using a case report.


  Case Report Top


A 45-year-old female presented to the outpatient department with complaints of abdominal discomfort, epigastric pain and nausea for the past 4 years. Upper abdominal discomfort was associated with meals. She also had complaints of borborgyme sensation in the abdomen along with gastric reflux post meals. Loss of appetite and loss of weight (22 kg) over the past 4 years were significant. She was an occasional smoker and alcoholic, had no other comorbidities but had undergone A lower segment Caesarean section (LSCS) in 1987 and attained menopause 1 year back. There was no family history of malignancies or any other chronic illnesses.

She was first evaluated on 5th August 2017, and investigations such as chest X-ray, electrocardiogram and computed tomography abdomen were done on 8th August 2017. Upper GI scopy on 14th August 2017 revealed normal oesophagus, antrum, pylorus-large circumferential proliferative growth, distal antrum, Pylorus-poorly differentiated adenocarcinoma with signet ring cells.

She underwent staging laparoscopy on 5th September 2017, which revealed primary tumour in distal stomach with no secondary inflammation (T3 N0 M0). She was on NG to dependent drainage, wound drains and IV fluids and ambulated on the 2nd post-operative day. She was initially started on sips of fluids, which was later increased to 30 ml/h and 60 ml/h and soft solids in the consecutive days. IV antibiotics, antiemetics, analgesics, ulcer prophylaxis and vitamin supplements were administered. Regular surgical wound dressing was done. Started on NACT from 13th September 2017-FLOT (5 fluorouracil, leucovorin, oxaliplatin and docetaxel) for four cycles, to 31th October 2017. Post-chemotherapy, she underwent subtotal gastrectomy Billroth 2 on 19th December 2017.

Nursing care

Preoperatively, the patient was counselled for fear, anxiety, knowledge deficit and nutrition.[18] Measures were taken to prevent infection. The post-operative care is presented below based on the needs and problems of the patient.

Nursing diagnosis

Risk for ineffective airway clearance related to pooling of secretions secondary to general anaesthesia.

Interventions

  • Assessed airway patency by checking bilateral air entry and breath sounds
  • Suction apparatus was kept ready to be used if required
  • Positioned the patient in semi-fowlers
  • Provided steam inhalation and chest physiotherapy TID along with nebulisation saline Q8H
  • Assisted with ambulation from the 2nd post-operative day
  • Ensured adequate hydration to easily liquefy secretions.


Evaluation

Patent airway was maintained as evidenced by normal breath sounds, normal rate and depth of respirations and ability to effectively cough up secretions after treatments and deep breaths.

Nursing diagnosis

Risk for ineffective breathing patterns related to the relaxation of smooth muscles secondary to general anaesthesia.

Interventions

  • Assessed respiratory rate, rhythm, quality, bilateral chest movements and saturation
  • Administered 4 L oxygen per minute through face mask for first 6 h postoperatively
  • Positioned in semi-fowler
  • Encouraged deep breathing exercises and incentive spirometry
  • Encouraged ambulation at least thrice a day.


Evaluation

She was able to maintain an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnoea.

Nursing diagnosis

Risk for decreased cardiac output related to blood loss during surgery.

Interventions

  • Monitored heart rate, blood pressure (BP), urine output, capillary refill and SpO2
  • Observed for signs of bleeding or oozing
  • Administered IV fluids
  • Monitored haemoglobin, platelet count and clotting time
  • Maintained intake-output chart.


Evaluation

She was able to demonstrate adequate cardiac output as evidenced by BP and pulse rate and rhythm within normal parameters for patient; strong peripheral pulses and an ability to tolerate activity without symptoms of dyspnoea, syncope or chest pain.

Nursing diagnosis

Acute pain related to surgical incision.

Interventions

  • Assessed pain score, location and characteristics Q4H. Pain was initially 7 then later reduced to 3
  • She was on epidural analgesia till the 4th post-operative day, when the use of buprenorphine patch was initiated and epidural infusion of fentanyl-bupivacaine was discontinued. Along with this, IV injection Voveran also helped in pain relief
  • Non-pharmacological measures such as positioning and use of comfort devices helped in making the patient pain free.


Evaluation

Pain was reduced as evidenced by decrease in pain score, normal vital signs.

Nursing diagnosis

Risk for imbalanced nutrition less than body requirement related to nausea, vomiting, Nil Per Oral (NPO) status and inadequate intake.

Interventions

  • Administered IV fluid according to the patient's needs
  • Started feeding orally after removal of NG-dependant drain
  • Started on clear fluids on the 2nd day at 30 ml/h and as the patient had no complaints, it was increased to 60 ml/h on the 3rd day and to soft diet on the 5th day
  • Administered antiemetic (injection Ondansetron) Q8H
  • Taught about the need to take injection Vitamin B12, IM every month to prevent pernicious anaemia
  • Once the patient started tolerating normal diet, she was taught about taking small, frequent meals rather than large ones and to include proteins, Vitamin C, iron and fibre-rich diet for better recovery.


Evaluation

She was able to maintain optimal nutritional status as evidenced by the absence of loss of weight and normal laboratory parameters.

Nursing diagnosis

Self-care deficit related to pain and fatigue secondary to surgery.

Interventions

  • Assisted in meeting hygienic, grooming, elimination needs and ambulation
  • Helped in position changing Q2H
  • Provided a clean and wrinkle-free bed
  • Ensured that the side rails were put on to avoid falls, and a relative was encouraged to be with the patient at all times.


Evaluation

She was able to maintain and self-care activities within limitations.

Nursing diagnosis

Risk for delayed surgical recovery related to complications secondary to surgery:

Interventions

  • Haemorrhage


    • Monitored vital signs
    • Assessed for any signs of abdominal pain or discomfort
    • Assessed for bleeding/oozing, monitored haemoglobin levels
    • Administered IV fluids or blood products as indicated.


  • Infection


    • Monitored vital signs and for signs of infection
    • Maintained aseptic techniques and hand hygiene strictly
    • Changed dressings daily
    • Ensured good personal hygiene and a clean environment
    • Administer prophylactic antibiotics.


  • Atelectasis


    • Monitored respiratory rate, rhythm and bilateral air entry
    • Encouraged use of incentive spirometry
    • Positioned in fowlers
    • Administered oxygen if needed
    • Encouraged ambulation
    • Provided adequate analgesia.


  • Dumping syndrome


    • Assessed for signs such as dizziness, diaphoresis and diarrhoea [Figure 4]
    • Advised small periodic meals and to lie in low fowlers for 20–30 min after diet intake
    • Administered antispasmodics
    • Instructed to avoid taking fluids with diet and to take complex carbohydrates instead of simple ones.
    Figure 4: Dumping Syndrome

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  • Deep vein thrombosis


    • Ensured use of thromboembolic deterrent stockings for 3 days
    • Administered anti-coagulants as ordered (injection Heparin 5000 IU S/C Q8H) for 3 days
    • Encouraged ambulation and leg exercises.


  • Anastomotic leak


    • Monitored wound drain output carefully
    • Assessed the characteristics of the drain contents
    • Assessed for any signs of abdominal discomfort and signs of peritonitis
    • Placed the patient on NG to dependant drain without NG aspiration to avoid pressure at the suture site.


  • Wound dehiscence/evisceration


    • Explained the need to avoid activities which increase intra-abdominal pressure
    • Used of abdominal binder
    • Encouraged them to splint the surgical site while coughing, sneezing, getting up, etc.


Evaluation

She did not develop any complications.

Nursing diagnosis

Deficient knowledge regarding home care and follow-up related to lack of information.

Interventions

  • Assessed level of knowledge and understanding on the teachings previously given (post-operative exercises, diet and pain management)
  • Explained about regular follow-up, medications, home care, prevention and detection of complications such as infection, incisional hernia and dumping syndrome
  • Encouraged them to clarify doubts and reinforced the information.


Evaluation

She verbalised her understanding about all the instructions given to her.


  Conclusion Top


Mrs. X surgery was uneventful, had hypotension on the 2nd post-operative day which was managed with IV fluids. On the 5th day, she was discharged as she was afebrile, tolerating oral diet well, had a healthy incision. Carcinoma stomach if identified and treated at an early stage has a good prognosis. However, patients present to the hospital only at an advanced stage. Appropriate counselling and prompt care will help patients to have a quick recovery and uneventful post-operative period.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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