Page 182 - Medicine and Surgery

P1: KOA
BLUK007-04 BLUK007-Kendall May 25, 2005 7:57 Char Count= 0

178 Chapter 4: Gastrointestinal system

reconstruction requires either a gastric pull up, or Gastric adenocarcinoma
asection of colononapedicle flap. Neoadjuvant
Definition
chemotherapy with cisplatin and 5-fluorouracil (5-
Malignant tumour of the stomach.
FU) improves short term survival over surgery alone.
Squamous cell carcinoma may be sensitive to radio-

therapy in inoperable cases, this is usually used in con- Incidence
junction with combination chemotherapy (chemora- 10 per 10,000 per year, accounts for 10% of cancer deaths
diation). Chemoradiation is the treatment of choice due to late presentation.
for localised squamous cell carcinoma of the proximal
oesophagus.
Palliative treatments include stricture dilation, or en-
Age
doscopic insertion of covered/uncovered metal stent, More than 30 years. Incidence rises above age 50 years.
argon plasma coagulation (APC) and laser.
Sex
Prognosis
2M > 1F
Surgical resection carries an operative mortality of up
to 20%. Prognosis remains poor with only 5% 5-year
survival. Geography
Highest in Japan and Chile.
Benign gastric tumours
Aetiology
Definition
Pre-malignant conditions include chronic atrophic gas-
Benign tumours and polyps of the stomach. These can
tritiswithintestinalmetaplasiaandadenomatouspolyps
be divided into epithelial and mesenchymal derived tu-
of the stomach.
mours:
H. pylori causes atrophic gastritis resulting in dyspl-
Epithelial derived, polypoid structures:
asia and neoplasia.
Hyperplastic polyps are common overgrowths of gas-

Dietary carcinogens possibly including nitrates and
tric mucosa often resulting from the healing of an
alcohol. Salt may be involved.
ulcer.
Adenomatous polyps are rare benign tumours of the

surface epithelium which may be single or multiple. Pathophysiology
They have a significant risk of malignant change most Gastric adenocarcinomas are derived from mucus se-
likely in large polyps. creting epithelial cells most occurring in the antrum.
Hamartomas are seen in Peutz–Jeghers syndrome. Tumours may be of three types:

Mesenchymal derived benign tumours: Ulcerating (most common) with appearance similar
Leiomyomas appear as mucosal or intramural nod- to benign ulcers but with raised edges and no normal

ules. mucosa.
Polypoidal which often bleed leading to earlier pre-

Clinical features sentation.
Most benign tumours are asymptomatic and found on Infiltrating when fibrous tissue causes a firm non-
endoscopy or barium meal. Rarely bleeding or obstruc- distendable or linitis plastica (leather bottle) stomach.
tion with vomiting may occur. It tends to present late with non-specific symptoms.
Spread may be direct invasion to the liver and pancreas,
Management transcoelomic spread resulting in a malignant ascites
Allsuspiciouspolypsrequireexaminationbyendoscopic and ovarian Krukenberg tumour, lymphatic spread to
excision biopsy, multiple polyps may require gastric re- regional and distant lymph nodes (Virkow’s node) and
section. Leiomyomas are treated by surgical excision. via the portal circulation to the liver.