FirstRanker Logo

FirstRanker.com - FirstRanker's Choice is a hub of Question Papers & Study Materials for B-Tech, B.E, M-Tech, MCA, M.Sc, MBBS, BDS, MBA, B.Sc, Degree, B.Sc Nursing, B-Pharmacy, D-Pharmacy, MD, Medical, Dental, Engineering students. All services of FirstRanker.com are FREE

📱

Get the MBBS Question Bank Android App

Access previous years' papers, solved question papers, notes, and more on the go!

Install From Play Store

Download MBBS Surgery Presentations 12 Carcinoma Stomach Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 12 Carcinoma Stomach PPT-Powerpoint Presentations and lecture notes

This post was last modified on 08 April 2022

--- Content provided by​ FirstRanker.com ---

Portal hypertension

Chronic liver disease

Carcinoma Stomach

--- Content provided by FirstRanker.com ---

Introduction

? Gastric cancer is endemic in Japan
? Late stage at diagnosis because of

--- Content provided by FirstRanker.com ---

? Low incidence

? Non specific symptoms

? Risk factors not definable

--- Content provided by FirstRanker.com ---


? Biological y more aggressive
? Increasing incidence of adenocarcinomas of proximal

stomach and distal esophagus

--- Content provided by‍ FirstRanker.com ---


Etiology

? Low acid production

--- Content provided by‌ FirstRanker.com ---

Body of stomach

? H pylori infection

? Low acid production

--- Content provided by FirstRanker.com ---


Esophagus & Cardia

? Reflux
? Obesity

--- Content provided by FirstRanker.com ---

? High BMI
? High glycaemic load diet
? GERD
? Smoking
? Alcohol

--- Content provided by FirstRanker.com ---

? Tobacco

Although no normal lymphoid tissue is found in the

gastric mucosa, the stomach is the most common site

--- Content provided by⁠ FirstRanker.com ---


for lymphomas of the gastrointestinal tract


Borrmann classification(depending on

--- Content provided by‍ FirstRanker.com ---


macroscopic appearance)

? Type I: polypoid or fungating cancers
? Type II: ulcerating lesions surrounded by elevated

--- Content provided by⁠ FirstRanker.com ---


borders

? Type II : ulcerated lesions infiltrating the gastric wall
? Type IV: diffusely infiltrating tumors

--- Content provided by⁠ FirstRanker.com ---

? Type V: unclassifiable cancers
Patterns of Spread

? Local extension
? Lymphatic metastases

--- Content provided by FirstRanker.com ---


? left supraclavicular fossa (Virchow's node)
? left axil a (Irish's node)
? S/c periumbilical tumour deposits (Sister Mary Joseph's nodes)

--- Content provided by⁠ FirstRanker.com ---

? Peritoneal metastases
? Distant metastases

Clinical Presentation

--- Content provided by​ FirstRanker.com ---

? Weight Loss
? Anorexia
? Early satiety (Diffusely infiltrative type)
? Recurrent Vomiting (pyloric involvement )
? Dysphagia

--- Content provided by FirstRanker.com ---

? Bleeding
? Anemia
? Fatigue
? Epigastric pain
? Ascites, jaundice, or palpable mass indicates incurable

--- Content provided by FirstRanker.com ---


disease

? Transverse colon is a potential site of malignant

--- Content provided by‌ FirstRanker.com ---

fistulization and obstruction from gastric primary tumor

? Diffuse peritoneal spread of disease frequently produces

other sites of intestinal obstruction

--- Content provided by‍ FirstRanker.com ---


? Large ovarian mass ( krukenberg's tumor)

? Large peritoneal implant in the pelvis ( blumer's shelf)

--- Content provided by⁠ FirstRanker.com ---

? Macroscopic description of the tumor

? Extent of peritoneal metastases (P0-1)

? Extent of hepatic metastases (H0-1)

--- Content provided by‌ FirstRanker.com ---


? Peritoneal cytology findings
Resection Classification

? R0: no gross or microscopic residual disease

--- Content provided by FirstRanker.com ---


? R1: microscopic residual disease (+ margins)

? R2: gross residual disease

--- Content provided by⁠ FirstRanker.com ---

Diagnostic work up

? Tumour Markers: CA 19.9,CA 72.4, CEA, CA 50
? Endoscopy & Biopsy:

--- Content provided by FirstRanker.com ---

? Chromo endoscopy: identification of mucosal abnormalities

through topical stains.

? Magnification Endoscopy: magnify standard endoscopic

--- Content provided by​ FirstRanker.com ---


fields by 1.5- to 150-fold.

? Narrow band imaging: increased visualization of the

--- Content provided by​ FirstRanker.com ---

microvasculature

? Confocal laser Endomicroscopy : 3D microscopy including

subsurface structures

--- Content provided by FirstRanker.com ---

? Overexpression or amplification of HER2 (EGFR2):

? occurs in approximately 20% of patients with

gastric cancer

--- Content provided by‍ FirstRanker.com ---


? Recommended in metastatic, recurrent gastric

cancer

--- Content provided by⁠ FirstRanker.com ---

? Trastuzumab used in Her 2 neu + cancers

? Endoscopic ultrasound (EUS)
? Computed Tomography
? Magnetic Resonance Imaging:

--- Content provided by‍ FirstRanker.com ---


? to characterize liver lesions on CT scan

? Positron Emission Tomography:

--- Content provided by FirstRanker.com ---

? 50% of primary tumors are FDG-negative
? diffuse (signet cel ) subtype most likely to be non-FDG

avid
? Staging Laparoscopy and Peritoneal Cytology:

--- Content provided by FirstRanker.com ---


? directly inspects the peritoneal and visceral surfaces

? done to spare nontherapeutic operations

--- Content provided by⁠ FirstRanker.com ---

Treatment

? Surgery (Gastrectomy with lymph node

dissection) `

--- Content provided by​ FirstRanker.com ---


? Radical Gastrectomy (Proximal gastric cancer)

? Subtotal Gastrectomy (mid & distal gastric cancer)

--- Content provided by‌ FirstRanker.com ---

When the oncologic goal of an R0 resection can be achieved by a gastric-

preserving approach, partial gastrectomy is preferred over total
gastrectomy

--- Content provided by FirstRanker.com ---


A: Subtotal gastrectomy with a Bil roth II anastomosis

B: Total gastrectomy with a Roux-en-Y anastomosis

--- Content provided by⁠ FirstRanker.com ---

? Lymphadenectomy

? 15 nodes for adequate pathologic staging


--- Content provided by FirstRanker.com ---


? Partial Pancreatectomy and Splenectomy--Resect or

Preserve?

--- Content provided by FirstRanker.com ---

Splenectomy:

? Intraoperative evidence of direct tumor extension into the

spleen

--- Content provided by‍ FirstRanker.com ---


? Primary tumor is located in the proximal stomach along

the greater curvature

--- Content provided by‍ FirstRanker.com ---

Partial Pancreatectomy:

? direct tumor extension into the pancreas


--- Content provided by​ FirstRanker.com ---

Stage specific Survival rates for gastric adenocarcinoma are

higher in Japan than in Western countries because:

? Better-prognosis intestinal-type tumors are more common

--- Content provided by⁠ FirstRanker.com ---


? Poorer-prognosis proximal gastric cancers are less frequent

? Widespread use of extensive D2 or D3 lymphadenectomy

--- Content provided by FirstRanker.com ---



Chemotherapy

? Adjuvant

--- Content provided by‌ FirstRanker.com ---


? Neoadjuvant:

? Higher rate of R0 resections
? Early treatment of micro metastatic disease

--- Content provided by FirstRanker.com ---


? Periperative
Adjuvant Intraperitoneal Chemotherapy

? Hyperthermic intraoperative peritoneal chemotherapy

--- Content provided by‌ FirstRanker.com ---


(HIPEC)

? Normothermic intraoperative chemotherapy (NI C)

--- Content provided by‍ FirstRanker.com ---

? Early postoperative intraperitoneal chemotherapy (EPIC)

? Delayed postoperative intraperitoneal chemotherapy (DPIC)

Chemotherapy Drugs

--- Content provided by FirstRanker.com ---


? Cisplatin
? 5-Fluorouracil
? Taxanes
? Epirubicin

--- Content provided by⁠ FirstRanker.com ---

? Irinotecan
? Trastuzumab (targeted therapy in Her 2 neu + )
Radiotherapy

? Preoperative

--- Content provided by‍ FirstRanker.com ---


? Intraoperative

? Postoperative

--- Content provided by‍ FirstRanker.com ---

Liver Tumours
Benign tumours

? Liver Cell Adenoma

--- Content provided by FirstRanker.com ---

? Focal Nodular hyperplasia

? Hemangioma

? Mesenchymal hamartomas

--- Content provided by​ FirstRanker.com ---


Liver Cell Adenoma

? benign proliferation of hepatocytes
? young women (aged 20-40 years)

--- Content provided by FirstRanker.com ---

? associated with use of oral contraceptive pills (OCPs)
? usually singular
? Upper abdominal pain
? tumor markers are normal
? MRI scans of LCA have specific imaging characteristics

--- Content provided by⁠ FirstRanker.com ---

? two major risks are rupture & malignant transformation
? Hepatic artery embolization
? Resection of the mass
Focal nodular hyperplasia
? Second most common benign tumor

--- Content provided by‍ FirstRanker.com ---

? young women
? small (<5 cm) nodular mass
? involves the right and left liver equally
? Related to developmental vascular malformation
? Nonspecific symptoms

--- Content provided by​ FirstRanker.com ---

? Contrast-enhanced CT and MRI scan
? Symptomatic pts: resection

Hemangioma
? Most common benign tumor of the liver

--- Content provided by‌ FirstRanker.com ---

? Women more common than men (3:1 ratio)
? Mean age of about 45 years
? Occur equally in the right and left liver
? Usually single
? Lesions > 5 cm are arbitrarily called giant hemangiomas

--- Content provided by‍ FirstRanker.com ---

? Tumor markers are usually normal
? CT and MRI scan
? Resection: enucleation with inflow control
Hepatocel ular carcinoma

--- Content provided by FirstRanker.com ---

Introduction

? Fifth most common malignancy worldwide

? Male-to-female ratio 2.4:1

--- Content provided by​ FirstRanker.com ---


? Poor prognosis
Etiology

? Infections with hepatitis B and C viruses

--- Content provided by‌ FirstRanker.com ---

? Ethanol abuse
? Obesity
? Type 2 diabetes
? Non-alcoholic fatty liver disease
? Aflatoxin B1

--- Content provided by‍ FirstRanker.com ---


Pathology

? Malignant epithelial neoplasms: 85% to 95%

--- Content provided by​ FirstRanker.com ---

? Benign: 6 %to 12%

? Malignant mesenchymal tumors: 1% to 3%

? Metastatic tumors

--- Content provided by⁠ FirstRanker.com ---

? Tumors metastatic to the liver are:

? Peripheral
? Multiple
? Cause umbilication of surface of the liver

--- Content provided by‌ FirstRanker.com ---


? Primary liver tumors are:

? Central
? Solitary

--- Content provided by‌ FirstRanker.com ---

? Exophytic

? HCC spreads most commonly to

? Lymph nodes around the liver

--- Content provided by‌ FirstRanker.com ---

? Peritoneal cavity
? Lung

Characteristic feature of HCC is invasion of the

--- Content provided by‌ FirstRanker.com ---

portal vein
Clinical Features

Symptoms

--- Content provided by​ FirstRanker.com ---

Signs

? Abdominal pain

? Hepatomegaly

--- Content provided by​ FirstRanker.com ---


? Weight loss

? Hepatic bruit
? Ascites

--- Content provided by‌ FirstRanker.com ---


? Weakness

? Splenomegaly

--- Content provided by‌ FirstRanker.com ---

? Ful ness

? Jaundice

? Anorexia

--- Content provided by FirstRanker.com ---


? Wasting

? Abdominal swel ing

--- Content provided by​ FirstRanker.com ---

? Fever

? Jaundice

? Virchow-Troisier nodes

--- Content provided by‌ FirstRanker.com ---


? Vomiting

? Cutaneous metastases (red-blue nodules)

--- Content provided by FirstRanker.com ---

Paraneoplastic Syndromes

? Hypoglycemia
? Erythrocytosis
? Hypercalcemia

--- Content provided by FirstRanker.com ---

? Hypercholesterolemia
? Dysfibrinogenemia
? Carcinoid syndrome
? Increased thyroxin-binding globulin
? Sexual changes (gynecomastia, testicular atrophy, and

--- Content provided by⁠ FirstRanker.com ---


precocious puberty)

? Porphyria cutanea tarda

--- Content provided by‌ FirstRanker.com ---


Diagnostic work up

? Liver function tests
? S. Alpha feto protein (70%)

--- Content provided by⁠ FirstRanker.com ---

? S.Des--carboxy prothrombin protein (80%)
? Four-phase CT scan: unenhanced, arterial, venous, and delayed

phases

--- Content provided by​ FirstRanker.com ---

? MR imaging

Characteristic feature of HCC: rapid enhancement during the

arterial phase of contrast administration and "washout" during

--- Content provided by‌ FirstRanker.com ---


the later portal venous and delayed phases

Portal venous phase of triphasic computed tomography scan

--- Content provided by‍ FirstRanker.com ---


? PET CT Scan: not recommended

? Core biopsy: hal mark feature of HCC is stromal invasion

--- Content provided by⁠ FirstRanker.com ---

CHILD PUGH score for assessment of hepatic reserve
Quantitative assessment of hepatic

reserve

--- Content provided by FirstRanker.com ---

Indocyanine green clearance test

? Retention rate <10%: all resections are possible
? 10% to 20%: bisegmentectomy is well tolerated
? 20% to 29%: single segment can be excised

--- Content provided by⁠ FirstRanker.com ---

? 30% or more: risk of liver failure is high

Management

Stage I and II HCC

--- Content provided by⁠ FirstRanker.com ---

? Surgical resection
? Local ablation (radiofrequency ablation)
? Local injection therapies (ethanol injection):

? maximum size of tumor reliably treated is 3 cm

--- Content provided by⁠ FirstRanker.com ---


? Transplantation
Child-Pugh A: Resection
Child-Pugh B and C patients with stage I HCC tumors : transplant, if
appropriate

--- Content provided by FirstRanker.com ---

Adjuvant Therapy

? Trans arterial chemotherapy (TACE)
? Systemic chemotherapy

--- Content provided by‌ FirstRanker.com ---

? Lipiodol
? Doxorubicin
? Mitomycin
? Cisplatin

--- Content provided by‍ FirstRanker.com ---

Stage II and IV Tumors
? TACE

? Regional Chemotherapy

--- Content provided by‍ FirstRanker.com ---

? Systemic Therapy

? External Radiotherapy (< 8 cm)

? Hepatic Arterial Radioisotopes

--- Content provided by FirstRanker.com ---


? yttrium-90 (90Y)
? 131 I antiferritin


--- Content provided by‍ FirstRanker.com ---

Portal Hypertension

Anatomy
? The normal portal pressure is 5-7 mmHg (8-12

--- Content provided by​ FirstRanker.com ---

cm of water).

? Portal hypertension is present when the portal

vein pressure exceeds 12 mmHg

--- Content provided by‌ FirstRanker.com ---


Causes

? Presinusoidal

--- Content provided by​ FirstRanker.com ---

? Sinusoidal

? Postsinusoidal


--- Content provided by​ FirstRanker.com ---

Sequelae & Clinical picture

? Porto-systemic collaterals

? Splenomegaly

--- Content provided by​ FirstRanker.com ---


? Congestion of the whole GIT

? Bleeding varices

--- Content provided by⁠ FirstRanker.com ---

? Ascites




--- Content provided by‍ FirstRanker.com ---

Intra-abdominal venous flow pathways leading to engorged veins

(varices) from portal hypertension

Screening Tests for Portal Hypertension

--- Content provided by‌ FirstRanker.com ---



? Ultrasound with doppler blood flow assessment.

? MRI venogram

--- Content provided by⁠ FirstRanker.com ---


? Contrast-enhanced helical CT scan


Detection of oesophageal varices

--- Content provided by‌ FirstRanker.com ---



Management

? Management of patients with actively bleeding

--- Content provided by FirstRanker.com ---


oesophageal varices

? Resuscitation
? Correct coagulopathy

--- Content provided by‍ FirstRanker.com ---

? Prevent encephalopathy
? Sclerotherapy
? Endoscopic Banding
? Drugs: Vasopressin,Somatostatin
? Balloon tamponade

--- Content provided by‍ FirstRanker.com ---


? Trans-juguJar Intra-hepatic Porto-Systemic Shunt
(TIPSS )
? Shunt operations

--- Content provided by FirstRanker.com ---

? Portocaval shunt
? Proximal spleno-renal shunt
? Mesocaval (Drapanas) shunt
? Selective shunt (Warren shunt)

--- Content provided by FirstRanker.com ---

? Liver Transplant

Chronic Liver

Disease

--- Content provided by FirstRanker.com ---






--- Content provided by⁠ FirstRanker.com ---


Catabolism of hormones

Glucose homeostasis;

--- Content provided by‌ FirstRanker.com ---

and other serum proteins

glycogenolysis & gluconeogenesis

Chronic Liver

--- Content provided by⁠ FirstRanker.com ---


Disease

Synthesis:

--- Content provided by‌ FirstRanker.com ---

- Albumin

- Coagulation factors

Storage:

--- Content provided by‌ FirstRanker.com ---


Bile excretion

- Glycogen

--- Content provided by‍ FirstRanker.com ---

- Iron

- Cu, Iron, vitamins

Signs of CLD

--- Content provided by‌ FirstRanker.com ---


Chronic Liver

Disease

--- Content provided by‌ FirstRanker.com ---


Investigations

Bedside
? Observations, BM, fluid balance, weight

--- Content provided by FirstRanker.com ---

Blood tests
? LFTs (pre/post) (including albumin), INR
? FBC, U&Es, CRP
? Liver screen: autoantibodies, alpha-1 antitrypsin, caeruloplasmin,

--- Content provided by FirstRanker.com ---

serum copper, ferritin, viral hepatitis serology

Imaging
? US abdomen + portal vein doppler
? CXR, CT, MRI, MRCP

--- Content provided by FirstRanker.com ---

Special tests
? Ascitic tap, OGD (oesophageal varices), liver biopsy

What is your management plan?

--- Content provided by FirstRanker.com ---

Conservative
? Alcohol abstinence, optimise nutrition, low salt diet, fluid restriction
Medical
? Vitamin B supplementation (IV/PO), chlordiazepoxide
? Diuretics

--- Content provided by‌ FirstRanker.com ---

? Paracentesis (give albumin)
? NG feeding
? Antibiotics (? SBP)
? Steroids + albumin (N.B. avoid NaCl)
? Lactulose (in hepatic encephalopathy)

--- Content provided by FirstRanker.com ---

Surgical
? TIPSS
? Liver transplantation


--- Content provided by FirstRanker.com ---

Complications of CLD

? Portal hypertension: oesophageal varices, ascites
? SBP
? Hepatic encephalopathy (constipation, GI bleed, infection, renal

--- Content provided by FirstRanker.com ---


failure)

? Hepatocel ular carcinoma
? Coagulopathy

--- Content provided by​ FirstRanker.com ---

? Hepato-renal syndrome
? Liver failure

? 5 year survival rate in cirrhotic CLD 50%
? Child Pugh Score: bilirubin, INR, albumin, ascites, hepatic

--- Content provided by​ FirstRanker.com ---


encephalopathy