1. Abdominal (Gastric Cancer) - Ahmad Abid
Solid organ (HCC) – Ahmad Ashraf
Upper extremities – Ahmad Danial
Lower extremities – Ahmad Farabi
Head and Neck- Adiba & Adibah
General – Khaireza (state of consciousness and hemorrhage)
5. More prominent in case of advanced gastric
cancer.
Early satiety,bloating,distension and vomiting may
occur.
If tumour bleeds will lead to iron def. anemia.
Obstruction will lead to dysphagia,epigastric fullness or
vomiting.
With pyloric involvement will lead to gastric outlet obst.
Metastatic LN may be palpable (Virchow’s Nodes)
6. Medical Hx/Phys. Exam (Signs and symptoms)
Lab tests – CBC, LFT,RFT,Carcinoembryonic
Ag. and CA19.9
EGD and Biopsy,EUS guided biopsy,CT guided
needle biopsy.
Imaging – Barium Swallow,CT Scan,MRI,CXR
for metastatic lesion.
9. Emergency surgery within 24h of
presentation for gastric malignancy is
extremely rare.
Presentation :
1. Haematemesis
2. Visceral perforation
3. Gastric Outlet Obstruction
PE : Severe abdomen tenderness suggests GI
bleeding assoc. with GI Obst,GI perforation
and bowel ischemia.
10. Two-staged procedural approach.
1. First stage – Control the perforation,bleeding
and obstruction.
(Emergency lifesaving intervention)
2. Second stage – Definitive gastrectomy with
LN dissection after histological confirmation
and accurate staging.
(Emergency cancer therapy)
11. Nasogastric aspiration with saline lavage.
(Detection intragastric bleeding,type of bleeding-
red blood/coffee ground,endoscopic
visualization,prevent aspiration of gastric
contents.)
12. General Measure : (fluid replacement,blood
transfusion,care of abdomen from further
trauma,cardiorespiratory support,Rx
comorbid disease like sepsis,coronary artery
disease.)
*EGD should be delayed until patient is adequately
resuscitated and stabilized.
13. Specific measures : EGD (procedure of choice,diagnostic
and therapeutic tool for UGIB)
1. Injection therapy (adrenaline)
2. Ablative therapy (electrocautery,argon
plasma coagulation)
3. Mechanical therapy (endoclips or banding)
May require surgery for bleeding control if
endoscopic measures for hemostasis fail.
16. Exploratory laparotomy and application of Omental patch (Graham patch)
Peritoneal washout - peritoneal cavity is to be irrigated with 10 liters of warm
saline solution to remove further contamination.
http://www.saudijgastro.com/article.asp?issn=1319-
3767;year=2011;volume=17;issue=2;spage=124;epage=128;aulast=Maghsoudi
17. Closed suction drainage/Jacksonn Patt drain placement.
Site : suprahepatic and infrahepatic recesses, the lesser sac,
the paracolic gutters, and pelvis.
18. Crystalloid solutions.
The goals of resuscitation focus on urinary
output, lactic acid levels, mean arterial
pressure, and central venous pressure
parameters.
20. Oral feeding is likely to be delayed.
Intraoperative placement of a jejunostomy
feeding tube may be benefit the patient.
Alternative : Intraoperative or postoperative
placement of a double lumen gastro-jejunal
tube.
Catheters - Parenteral nutrition sometimes used.
*Generally, enteral nutrition distal to the perforation would be
preferable if possible.
http://emedicine.medscape.com/article/1892935-overview#aw2aab6b5
http://patients.gi.org/topics/enteral-and-parenteral-nutrition/
21. “Antimicrobial therapy should be continued postoperatively
for 24 hours when the perforation has been surgically closed
in the first 12 hours” - Infectious Guidelines of the Disease Society of
America and Surgical Infection Society
Goals : Normalization of WBC counts and temperature after
24h postoperatively.
If does not occur,antimicrobials can be continued for 4-7
days.
Preferred agents include a beta-lactam/beta-lactamase
inhibitor combination or a carbapenem.
H pylori eradication should also be considered.
http://emedicine.medscape.com/article/1892935-overview#aw2aab6b5
22. Following patient recovery and histological
confirmation of malignancy, accurate disease
staging can be completed, and a radical
oncological operation for gastric cancer or
neoadjuvant chemotherapy can be planned as
appropriately.
