This document presents two case studies of patients with gastric cancer. The first case is a 60-year-old male who presented with epigastric pain and vomiting for two months. Various tests were performed and it was determined that he had a signet ring cell type adenocarcinoma of the stomach. He underwent a laparoscopic gastrectomy. The second case is a 72-year-old male who also presented with epigastric pain and chest heaviness. He was found to have adenocarcinoma of the stomach as well and underwent a laparoscopic gastrectomy. The document then provides further details on the anatomy, histopathology, classification, staging, signs and symptoms, and management of
UG CASE PRESENTATION ON INGUINAL HERNIAAyesha Huma
I have added viva notes after this proforma for quick revision of important stuff asked in exam.
LINK FOR EXAMINATION VIDOES :
1. https://youtu.be/uO-w_9w5okI
2. https://youtu.be/Vc_ZH_-Oad4
CASE PRESENTATION ONCIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC EN...Akhil Joseph
A DETAIL CASE PRESENTATION ON CIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC ENCEPHALOPATHY AND GRADE II OESOPHAGEAL VARICES WITH CONGESTIVE GASTROPATHY. LIVER CIRRHOSIS AND ALL ITS COMPLICATION IN A PATIENT.
[MBBS/MS/DNB] Sample EXAM Long Case on Breast Lump Dr. Shouptik Basu
LABC IS A VERY COMMON LONG CASE for examinations.
This presentation describes the method to present or document your case sheets for MBBS, MS, or DNB examinees. Subtle differences may vary from UG to PG standard, this is a summary for a postgraduate trainee, underagraduates may have a few relaxations on a few specific terminologies, however, the gross pattern is the same.
UG CASE PRESENTATION ON INGUINAL HERNIAAyesha Huma
I have added viva notes after this proforma for quick revision of important stuff asked in exam.
LINK FOR EXAMINATION VIDOES :
1. https://youtu.be/uO-w_9w5okI
2. https://youtu.be/Vc_ZH_-Oad4
CASE PRESENTATION ONCIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC EN...Akhil Joseph
A DETAIL CASE PRESENTATION ON CIRRHOSIS OF LIVER WITH PORTAL HYPERTENSION, HEPATIC ENCEPHALOPATHY AND GRADE II OESOPHAGEAL VARICES WITH CONGESTIVE GASTROPATHY. LIVER CIRRHOSIS AND ALL ITS COMPLICATION IN A PATIENT.
[MBBS/MS/DNB] Sample EXAM Long Case on Breast Lump Dr. Shouptik Basu
LABC IS A VERY COMMON LONG CASE for examinations.
This presentation describes the method to present or document your case sheets for MBBS, MS, or DNB examinees. Subtle differences may vary from UG to PG standard, this is a summary for a postgraduate trainee, underagraduates may have a few relaxations on a few specific terminologies, however, the gross pattern is the same.
Abdomen and liver case presentation by PGKurian Joseph
Abdomen and liver case presentation by PG
Chronic decompensated parenchymal liver disease - cirrhosis with portal hypertension probably of alcoholic etiology with no ascites with no features of hepatic encephalopathy and coagulopathy
To rule out malignancy
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
2. Name : MR . X Y Z
Age: 60yrs, male
Religion: Islam
Marital
status: Married
Profession : Helper in CDA hospital
Address: Barakoh Islamabad
DOA: 28-07-2015 at 12 PM
BIO DATA
4. HISTORY OF PRESENT ILLNESS
My patient was living a healthy life 2 months back, when he developed
Epigastric pain, it was
gradual in onset ,
localized
non radiating ,
intermittent burning in character,
mild in severity, constant between meals, periodically lasting 7-14 days.
aggravated by food (spicy) and
relieved by walking and intake of milk and juices.
associated with bloating weight loss and vomiting
There is also h/o Weight loss, though not documented, but patient says
that his clothes became lose in last 2 months.
no relation of posture with pain.
Cont’d…
No h/o of haemetmesis, melena, heart
burn, large bulky greasy stools and altered
bowel habits.
He consulted a local doctor, who gave
him PPIs with which he only got
temporary relief.
5. After 4 weeks he also developed intractable Vomiting
occurs after having 2-3 meals,
frequency 1 episode /day usually in the morning. (2-3 times in
each go till the vomitus becomes watery).
projectile in nature,
containing mostly semi digested food particals,
yellowish in colour with offensive acidic smell,
associated with epigastric pain.
Aggravated by intake of meal and relieved by limatation of meal.
no associated complain of hemetemasis ,RHC pain with or without
jaundice, polyuria, polydipsia, unconsciousness, headache or
vertigo.
Cont’d
6. PAST MEDICAL AND SURGICAL HISTORY.
MNG for last 15 years.
Surgical Hx
In past he took PPI and
anti hyperthyoid drugs
for 1 month but later on
he was not complaint .
Hospital admission for 7
days in emergency as he
had sudden complete
right side visual loss.
7. FAMILY AND PERSONAL HISTORY
Mother also suffered from multinodular goiter and never was
complaint to medicine.
Married since 40 years with 4 children they are not suffering
from any significant disease.
He ia a smoker since 45 years 1-2 pack initially.
Sleep is not disturbed and appetite normal.
He has good social healthy term with family & friends.
Home surrounding is also clean with proper sanitation.
8. GPE EXAMINATION
An old gentleman of normal built, alert and
well oriented in time, space and person
sitting comfortably on the bed,
GCS 15/15
I/V line maintained in left forarm
Vitals:
Pulse 89/min
B.P: 120/80
RR: 18/min
BMI: 19.31
Cont’d
9.
10. FACE: No signs of puffiness, proptosis, xanthelasma
TOUNGUE:dryness present ,size of toungue
normal.no sign of jaundice or cynosis.
Colour of conjuntiva:its dirty and hazy. Rt eye has
cornea is not visible with blind eye .no sign of jaundice or
pallor
NECK
Thyroid:Inspection:enlarged swelling moving up with
deglutition and bosselated
palpation:diffuse enlarge pin size multiple nodules
consistency is firm no tenderness and no pressure effect
No sign of thyrotoxicosis berry sign –ve and pamberton sign –ve
percussion:no extension to retersternal goiter
Auscultation:No bruit
LYMPH NODE:NOT PALPABLE
FEET: NO DEFORMITY OR EDEMA
11. GIT:
Tender epigastric region with succession
splash otherwise abdomen soft , non
tender & no visceromegaly. BS +ve
Respiratory system:
Normal B/L vesicular breathing
with no added sounds.
CVS: S1+S2+0
CNS:GCS 15/15, well oriented
14. SPECIFIC INVESTIGATION
CT SCAN ABDOMEN AND PELVIS WITH IV CONTRAST
IMPRESSION: Markedly distended stomach representing gastric
outlet obstruction with irregular thickness and pyloric growth most
likely represent gastric mass
CONCLUSION: Gastruc outlet obstruction due to an ulcerating
polypoidal mass
OPINION:poorly differentiated adenocarcinoma
(signet ring cell type)
16. PRE OP MANAGEMENT
1.NG TUBE WAS PASSED
2. Cathertize the patient
3. Iv antibiotics
4. TPN
5. Arrangment of blood
6. High risk consent
7.Monitoring of electrolytes
19. POST OPERATIVE CARE:
Keep patient in intensive care unit
Strict monitoring of electrolyte balance
Keep a check on drainage (ng,abdomianl/pelvis drains)
Monitor hourly vitals
Iv antibiotics
Iv pain killers
1st OP DAY 7TH POST OP DAY
REFERRED TO NOORI HOSPITAL
22. Name : Mr.X Y Z
Age: 72yrs, male
Religion: Islam
Marital
status: Married
Profession : EX ASSISTANT
DIRECTOR
Address: ISLAMABAD
DOA: 06-10-2015 at 10 AM
BIO DATA
24. HISTORY OF PRESENT ILLNESS
My patient was living a healthy life 3 months back,
when he developed Epigastric pain, it was
gradual in onset ,
localized to epigastric region radiating laterally ,
Intermittent but recently continous & burning in
character,
mild in severity, n it relieved after taking meals.
aggravated by food (spicy) and
relieved by taking risek but recently it was ineffective.
associated with bloating , dyspepsia weight loss and
epigastric fullness
no relation of posture with pain.
Cont’d…
No h/o of haemetmesis, melena, heart
burn, large bulky greasy stools and altered
bowel habits.
He consulted a local doctor, who gave
him PPIs with which he only got temporary
relief.
25. PAST MEDICAL AND SURGICAL HISTORY:
HTN
Surgical Hx
He is taking anti-
hypertenive drug
HAEMMORIDECTOMY
done in 1984.
26. GPE EXAMINATION
An old gentleman of normal built, alert and
well oriented in time, space and person
sitting comfortably on the bed,
GCS 15/15
I/V line maintained in left forarm
Vitals:
Pulse 70/min
B.P: 110/70
RR: 18/min
BMI: 28.1 over weight
Cont’d
PALLOR
27. GIT:
Tender epigastric region with succession splash
otherwise abdomen soft , non tender & no visceromegaly.
BS +ve
Respiratory system:
Normal B/L vesicular breathing
with no added sounds.
CVS: S1+S2+0
CNS:GCS 15/15, well oriented
28. INVESTIGATION
Blood cp
WBC: 9.6
HB: 6.3 mg/dl
Plt:
ESR: 80
LFTS
ALKALINE
PHOSPHTASE:
ALT
RFTS
UREA
CREATININE :
1.5
PT
APTT
INR
S/E
K : 4.2
FERRITIN : 11
NA : 134
HEPATITIS profile : NEGATIVE
URINE R/E : NORMAL
URINE C/S: NO GROWTH
STOOL OCULT: N/S
Chest xray : NORMAL
ECG :
29. •ECHO: GOOD LV SYSTOLIC & GRADE-
1 DIASTOLIC DYSFUNCTION
•U/S KUB LEFT RENAL CYST ,BPH
&DIVERTICULUM
•U/S ABDOMEN PYLORIC MASS,HEPATOMEGALY
&B/L RENAL CYST
SPECIFIC INVESTIGATIONS
31. PRE OP MANAGEMENT
1.NG TUBE WAS PASSED
2. Cathertize the patient
3. Iv antibiotics
4. TPN
5. Arrangment of blood
6. High risk consent
7.Monitoring of electrolytes
34. POST OPERATIVE CARE:
Keep patient in intensive care unit
Strict monitoring of electrolyte balance
Keep a check on drainage (ng,abdomianl/pelvis drains)
Monitor hourly vitals
Iv antibiotics
Iv pain killers
3RD POST OP DAY
35.
36.
37. OBJECTIVES :
CONT…
• TO EXPLAIN THE ANATOMY OF STOMACH.
• TO DESCRIBE ABOUT HISTOPATHOLOGY AND BLOOD SUPPLY
• TO CLASSIFY GASTRIC CA.
• TO EXPLAIN REGARDING TNM STAGING.
• TO DISCUSS SIGN & SYMPTOMS.
• HOW TO INVESTIGATE AND MANAGE GASTRIC CA
38. ANATOMY:
The stomach J-shaped. The stomach has two surfaces (the anterior & posterior), two curvatures (the greater &
lesser), two orifices (the cardia & pylorus). It has fundus, body and pyloric antrum.
The stomach begins at the gastroesophageal junction and ends at the duodenum. The stomach has 3 parts. The
uppermost part of the stomach is the cardia, and the largest and middle part is called the body. The distal portion of
the stomach, the pylorus, connects to the duodenum.
These anatomic zones have distinct histologic features. The cardia contains predominantly mucin-secreting cells.
The fundus (ie, body) contains mucoid cells, chief cells, and parietal cells, while the pylorus is composed of mucus-
producing cells and endocrine cells.
. Approximately 40% of cancers develop in the lower part, 40% in the middle part, and 15% in the upper
part, and 10% involve more than one part of the organ
39. BLOOD SUPPLY:ARTERIAL SUPPLY
a. The left gastric artery
b. Right gastric artery
c. Right gastro-epiploic artery
d. Left gastro-epiploic artery
e. Short gastric arteries
The corresponding veins drain into portal system.
The lymphatic drainage of the stomach corresponding
its blood supply.
40. LYMPH NODES
Gastric Lymphatics
Numbering of the gastric and upper abdominal node stations
Station no. Anatomical location
1, 2 Adjacent to the cardia (perigastric)
3, 4 Adjacent to lesser and greatercurve
5 Suprapyloric (right gastric artery)
6 Infrapyloric
7 Left gastric artery
8 Common hepatic artery
9 Coeliac artery
10 Hilum of the spleen
11 Splenic artery
12 Hepaticoduodenal ligament
13 Behind pancreatic head
14 At the root of the mesentery (superior mesenteric artery)
15 Middle colic artery
16 Para-aortic
41. STOMACH 4 ZONE OF LYMPHATIC DRAINAGE
I – 2/3 lesser curvature & large part of the body
Lt gastric nodes Celiac nodes
II – distal part of lesser curvature & pylorus
Rt. gastric nodes Supra-pyloric nodes
Hepatic nodes Celiac & Aortic LN
42. STOMACH 4 ZONES OF LYMPHATIC DRAINAGE
III- lt. part of greater curvature LGE nodes Pancreatic –Lineal
nodes Celiac
IV- rt. part of the greater curvature and pylorus RGE nodes
Pyloric nodes ( ant. surface of the pancreas) Supra-pyloric (
along gastro-duodenal artery) Hepatic nodes
43. STOMACH RELATIONS AND HISTOLOGY
Mucosa
Epithelium, lamina propria, and muscularis
mucosae*
Submucosa
Smooth muscle layer
Subserosa
Serosa
44. EPIDEMIOLOGY
Gastric cancer is the second most common fatal cancer in the world
wide with high frequency in Japan.
The disease presents most commonly in the 5th and 6th decades of life
and affect males twice as often as females.
Contn…
45. Etiological Factors of Gastric Cancer
Gastric
Cancer
H. Pylori
Genetic
factors
Envionmental
factors
Precancerous
changes
Blood group A
Male gender
Family history
Atrophic gastritis
Chronic gastric ulcer
Adenomatous polyps
Achlorhydria
Polyposis syndrome
Previous gastric resection
Menetrier disease
Micronutrition
Eating salted /smoked food
Diets high in nitrates and pickled food
Poor food storage
Lower socioeconomic status
Diet deficient inVegetable/fruit
Tobacco /alcohol/smoking
49. PATHOLOGY OF GASTRIC (MALIGNANT)
TUMOURS:
The gastric cancer may arise in the antrum
(50%), the gastric body (30%), the fundus or
oesophago-gastric juntion (20%).
50. PATHOLOGIC CLASSIFICATIONS
Borrmann’s Gross Morphology
Lauren’s Histopathology (cohesiveness)
WHO Histopathology (grade and growth)
Ming Histopathology (growth and pattern)
Goeski Histhopathology (atypia & mucin)
51. Early Gastric Cancer:
Defined as cancer which is confined to the mucosa and
submucosa regard- less of lymph nodes status.
Advanced Gastric Cancer:
Defined as tumor that has involved the muscularis propria of
the stomach wall.
52. Early Gastric Cancer
The term 'early gastric cancer' is used to describe
tumours confined to the gastric mucosa and submucosa,
irrespective of nodal status, and was elaborated in 1962
by the Japanese Society of Gastroenterological
Endoscopy
Type I Exophytic lesion extending into the gastric lumen
Type II Superficial variant
II A Elevated lesions with a height no more than the
thickness of the adjacent mucosa
II B Flat lesions
II C Depressed lesions with an eroded but not
deeply ulcerated appearance
Type III Excavated lesions that may extend into the
muscularis propria without invasion of this layer by actual
cancer cells
52
53. GASTRIC CARCINOMA
Diffuse(70%)
M:F 1:1
Onset Middle Age
5 yr surv overall <10%
Aetiology
Diet
H. pylori
Intestinal(30%)
M:F 2:1
Commonly seen in elderly men
Distal stomach
5 yr surv overall 20%
Aetiology
Unknown
Blood group A association
H. pylori
LAURENS CLASSIFICATION
54. ADVANCED GASTRIC CANCER:
The vast majority of gastric cancer are of advanced which deeply penetrate the stomach wall,
invade the adjacent structures with lymphatic & haematogenous metastasis.
Advanced gastric cancer classified according to the Bormann's morphologic description as –
Borrmann I: Fungating
Borrmann II: Carcimatous ulcer without infiltrating surrounding
mucosa
Borrmann III: Carcimatous ulcer with infiltration of surrounding
mucosa
Borrmann IV: Diffuse infiltrating carcinoma
55. STAGING OF GASTRIC CANCER:
a. TNM System
b. CT Staging
c. PHNS Staging System (Japanese)
P-factor (Peritoneal dissemination)
H-factor (The presence of hepatic
metastases)
N-factor (Lymphnodes involvement)
S-factor (Serosal invasion)
56. TX-Primary tumor cannot be assessed
T0- No evidence of primary tumor
Tis- intraepithelial,without invasion of lamina propria
T1- tumor invades lamina propria or submucosa
T2- tumor invades the muscularis propria
T3- tumor penetrates the serosa without invading adjacent structures ;
T4- Tumor invades adjacent structures
57. TNM Classification of Carcinoma of the Stomach-contd.
Regional lymph nodes (N)
NX Regional lymph node(s) cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1 to 6 regional lymph nodes(perigastric groups)
N2 Metastasis in 7 to 15 regional lymph nodes(coeliac groups)
N3 Metastasis in more than 15 regional lymph nodes(para-aortic groups)
Distant metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Lymph node station numbers as defined by the Japanese Gastric Cancer
Association
23 July 2016DR. RUBEL,SBMC
57
58. EVALUATION OF GASTRIC CANCER:
History
Clinical Examination
Investigations
The clinical features of gastric cancer may arise
from local disease, its complications or its
metastases.
59. CLINICAL FEATURES
SYMPTOMS
CLASSICAL HUNGER PAIN
DISTENSION OF UPPER ABDOMEN WITH EPIGASTRIC FULLNESS
VOMITTING
Projectile
Nature: Solids, then liquids
Type: Bile stained or not
Timing: Usually within an hour of a meal
1. Often asymmtomatic until late
stage
2. Weight loss due to anorexia and
early satiety is the most common
symptoms
3. Chronic occult blood loss is
common;
GIT bleeding (5%)
5. Dysphagia (cardia involvement)
6. Cachexia
60. SIGNS
Look at the patient!
Dehydrated
Cachecxic
Basic observations
Tachycardia
Examination
Often unremarkable
VISIBLE GASTRIC PERISTALSIS
(Stomach that you Feel)
SUCCESSION SLASH
(Stomach that you hear)
61. Clinical Manifestation:
6. Paraneoplastic syndromes ( Trousseau’s syndrome –
thrombophlebitis; acanthosis nigricans – hyperpigmentation
of axilla and groin; peripheral neuropathy)
7. Signs of distant metastasis:
a. Hepatosplenomegally with ascites& jaundice
b. Krukenbergs tumor(enlarged ovaries on p/E
c. Blummers shelf i.e fullness in the pelvis cul –de- sac ( drop
metastasis)
d. Virchow’s node (enlarged supraclavicular nodes)
e. Sister Joseph node i.e infilteration of umblicus.(pathognomonic
of advances dse)
62. SPREAD OF GASTRIC CANCER:
The diffuse type spreads rapidly through the submucosal and
serosal lymphatic and penetrates the gastric wall at early stage
the intestinal variety remains localized for a while and has
less tendency to disseminate.
The spread by:
1. Direct (loco regional)
2. Lymphatic
3. Blood (Haematogenous)
4. Transcoelomic
63. Lab Studies
The goal of obtaining laboratory studies is to assist in determining optimal therapy.
A complete blood cell count
can identify anemia, which may be caused by bleeding, liver dysfunction,
or poor nutrition. Approximately 30% of patients have anemia.
Electrolyte panels and liver function tests
also are essential to better characterize the patient's clinical state.
Carcinoembryonic antigen (CEA)
is increased in 45-50% of cases.
Cancer antigen (CA) 19-9
is elevated in about 20%of cases.
63
64. INVESTIGATIONS:
A. Upper gastero intestinal endoscopy
with multiple biopsy and brush
cytology
B. Radiology:
CT Scan of the chest and abdomen
USS upper abdomen
Barium meal
C. Diagnostic laparoscopy
•Inspect peritoneal surfaces, liver surface.
•Identification of advanced disease avoids
non-therapeutic laparotomy in 25%.
•Patients with small volume metastases in
peritoneum or liver have a life expectancy
of 3-9 months, thus rarely benefit from
palliative resection.
65. 1.UGIS (double contrast)
2.Endoscopy (Biopsy / Ultrasound)
GOLD STANDARD
Best pre-operative staging
Needle aspiration of LN w/ ultrasound guidance
Can even give preop neoadjuvant tx
3.CT scan (intravenous and oral contrast):
For pre-operative staging
4.Whole body Positron Emission Tomography scanning (PET):
Tumor cell preferentially accumulate positron-emitting 18F
fluorodeoxyglucose.
5.Laparoscopy
Investigations for patients with gastric cancer
66. SCREENING OF GASTRIC CANCER
Patients at risk for gastric CA should undergo yearly
endoscopy and biopsy:
1. Familial adenomatous polyposis
2. Hereditary nonpolyposis colorectal cancer
3. Gastric adenomas
4. Menetrier’s disease
5. Intestinal metaplasia or dysplasia
6. Remote gastrectomy or gastrojejunostomy
67. GOAL OF TREATMENT
Optimize the patient
Resection of all tumor
All margins (proximal, distal, and radial) should be negative
and an adequate lymphadenectomy performed
Negative margin of at least 5 cm
PosTop care of patient nutritonal &
dietery status.
68. STEP OF MANAGEMENT:
1. extent of surgical resection
A. proximal tumour
B mid body tumour
C distal tumour
Endoscopic treatment
EMR (endoscopic mucosal resection)
Ablation
Laproscopic gastric resection
2.extent of lymphadenectomy
3. adjuvant therapy
Adjuvant combined modality therapy
Neoadjuvant therapy chemotherapy
4. palliative therapy
The extent of gastric
resection depends on:
- Tumor size
- location
- Depth of invasion
- Histological type
69. ENDOSCOPIC RESECTION OF GASTRIC CARCINOMA
Criteria:
1. Tumor < 2cm in size
2. Node negative
3. Tumor confined on the mucosa
Nodes metastasis is < 1%:
1. No mucosal ulceration
2. No lymphatic invasions
3. <3cm tumor
70. TREATMENT:
SURGERY:
Radical subtotal gastrectomy
Standard operation for gastric cancer
Organs resected:
1. Distal 75% of stomach
2. 2 cm of duodenum
3. Greater & lesser omentum
4. Ligation of R & L gastric artery and
gastroepiploic vesels
5. Billroth II gastojejunostomy
71. TREATMENTS OF GASTRIC CANCER:
Surgery (Early or Advanced Cancer)
Proximal tumours which involve the fundus, cardia or body (total
gasterectomy)
75. 23 July 2016DR. RUBEL,SBMC
75
Surgical Treatment-contd.
The main controversy relates to the extent of lymph node dissection. Types of resective surgery have been
classified based on this criterion as follows:
1. R1: complete removal of perigastric lymph nodes;
2. R2: resection of perigastric nodes and those along the left gastric, splenic, and right hepatic
arteries;
3. R3: R2 with dissection of celiac axis nodes;
4. R4: R3 with dissection of paraaortic nodes.
Five-Year Survival Rate of Patients with Stomach Cancer
Tumor stage % Survival
R1 resection R2 resection
IA 88 91
IB 56 85
II 39 58
IIIA 7 30
IIIB 0 12
76. WHAT IS THE IDEAL EXTENT OF LYMPHADENECTOMY ?
D0- removes less than all relevant N1 nodes
D1- removes N1 nodes only
- Lt and Rt cardiac
- Lt and Rt gastro-epiploic
- Sub and Supra pyloric
D2- removes all N1 and N2 nodes
- Lt gastric
- Common hepatic
- Celiac
- Splenic hilum and along splenic artery
D3- removes all N2 and N3 nodes
77. EXTENT OF LYMPHADENECTOMY
The Japanese Research Society for Gastric Cancer numbered the lymph node
stations that potentially drain the stomach
Generally these are grouped into
level D1 ( stations 3 to 6),
level D2 ( stations 1, 2, 7, 8, and 11) &
level D3 ( stations 9, 10, and 12) nodes
D1 nodes are perigastric
D2 nodes are along the hepatic and splenic arteries
D3 nodes are the most distant
78. LYMPHADENECTOMY
The extent of resection is described as
D1. Limited Lymphadenectomy. All N1
Nodes removed en bloc with the stomach
D2. Systematic Lymphadenectomy. N1 &
N2 nodes en bloc with stomach
D3. Extended Lymphadenectomy. A more
radical en bloc resection including N3
nodes
79. POST OP COMPLICATIONS
Early complications
Paralytic ileus.
Leakage from suture line.
Leakage from duodenal stump.
Acute Cholycystitis, Pancreatitis
Stomal obstruction.
Late complications
• Early Dumping syndrome
• Late dumping syndrome.
• Bilious vomiting.
• Gastric stump cancer
• Vit B12 deficiency
• Osteoporosis
80. NEO ADJUVANT CHEMOTHERAPY
Downstaging of disease to increase resectability,
Decrease micrometastatic disease burden prior to surgery
Allow patient tolerability prior to surgery
Determine chemotherapy sensitivity
Reduce the rate of local and distant recurrences, and ultimately
improve survival.
81. CHEMOTHERAPY
Chemotherapy for gastric
cancer
(Pre-operatve & post-
operative)
The most widely used regimen is
5-FU, doxorubicin, and
mitomycin-c. The addition of
leukovorin did not increase
response rates.
Radiotherapy
(Pre-intra & post-
operatively)
Radiotherapy- studies show
improved survival, lower rates of
local recurrence when compared to
surgery alone.
In unresectable patients, higher 4
year survival with mutimodal tx, in
comparison to chemo alone.
RADIOTHERAPY
82. PALLIATIVE CARE
Radiotherapy provides relief from bleeding, obstruction, and pain
in 50-75%
Median duration of palliation is 4-18 months.
Advanced Unresectable Disease
Surgery is for palliation, pain, allowing oral intake
Wide local excision, partial gastrectomy, total gastrectomy, simple
laparotomy, gastrointestinal anastomosis, and bypass for food intake or
pain relief
83. RESULTS OF THERAPY – STOMACH CANCER
Surgery with curative intent
42% of patients
5 year survival – 60%
Node positive - 35%
Node negative - 88%
85. HAVE WE MET OUR OBJECTIVES?
Do we know the different types of obstruction?
Do understand the symptomatology?
Do we know the concepts of initial management?