Stomach Cancer (Gastric Carcinoma): Complications

The following are the most important diseases or complications that can be caused by gastric carcinoma (stomach cancer):

Blood, blood-forming organs – Immune system (D50-D90).

Mouth, esophagus (esophagus), stomach and intestines (K00-K67; K90-K93).

  • Gastroesophageal reflux disease (synonyms: GERD, gastroesophageal reflux disease; gastroesophageal reflux disease (GERD); gastroesophageal reflux disease (reflux disease); gastroesophageal reflux; reflux esophagitis; reflux disease; Reflux esophagitis; peptic esophagitis) – inflammatory disease of the esophagus (esophagitis) caused by the pathological reflux (reflux) of acid gastric juice and other gastric contents.

Neoplasms – tumor diseases (C00-D48) metastasis (formation of daughter tumors) occurs early:

  • Lymph nodes – early metastasis to the lymph nodes in the major and minor curvature, truncus coeliacus, paraaortic and mesenteric (70% of patients already have lymph node metastases at diagnosis).
  • Infiltration in:
    • Esophagus (food pipe
    • Duodenum (duodenum)
    • Colon (large intestine)
    • Pancreas (pancreas)
  • Hematogenous (“occurring by blood route”) metastasis (in advanced stages):
    • Brain
    • Lungs
    • Liver
    • Ovary/ovary (usually bilateral/both sides) → Krukenberg tumor (fibrosarcoma ovarii mucocellulare carcinomatodes) – ovarian metastases of gastrointestinal carcinoma (histology: mucus-filled signet ring cells → drip metastases of primary gastric carcinoma/stomach cancer).
    • Skeleton
  • Peritoneum (abdominal skin) – peritoneal carcinomatosis/peritoneal carcinomatosis (ascites/abdominal dropsy).

Consequential diseases or complications after gastric resection (partial stomach removal) or gastrectomy (stomach removal):

  • Alkaline reflux esophagitis – esophagitis in which gastric acid and pepsin play no role.
  • Anastomotic stenosis – narrowing of the connecting suture.
  • Anastomosis ulcer – formation of ulcers in the area of the connecting suture.
  • Bleeding
  • Dumping syndrome (postgastrectomy syndrome)
  • Iron deficiency anemia – anemia due to iron deficiency.
  • Infections
  • Malnutrition (malnutrition)
  • Suture insufficiency – inability of the suture to adapt the tissues.
  • Incisional hernia – abdominal wall hernia in the area of the surgical scar.
  • Pneumonia (pneumonia)
  • Thromboembolism – occlusion of a pulmonary artery by a blood clot.
  • Wound healing disorders

Dumping syndrome (postgastrectomy syndrome)

Surgical procedures on the stomach, especially subtotal or total gastric resection/partial or total removal of the stomach (= gastrectomy), lead to disturbances of essential functional processes of the upper digestive organ. Essential is the loss of the storage function. The stomach is no longer able to deliver the food pulp to the duodenum in a dosed manner. Under such circumstances, the food is transported uncontrollably into the upper small intestine. This precipitous transfer can trigger a complex of symptoms known as “dumping syndrome”. A distinction is made between early dumping, which occurs a short time after food intake, and so-called late dumping (postalimentary late syndrome). The latter occurs approximately 2-4 hours after food intake:

  • Early dumping syndrome: this is caused by distension of the upper small intestine due to the sudden onset of hyperosmolar food. Furthermore, due to hyperosmolarity (increased osmotic pressure in the blood), there is an increased influx of fluid from the bloodstream into the intestine. This further increases unphysiological wall distension. This influx of water into the bowel leads to systemic hypovolemia (decrease in blood volume) and consequently to a drop in blood pressure.
  • Late dumping syndrome: Late dumping syndrome, which occurs much later, results from a drop in serum glucose levels.The food pulp has a high osmotic pressure, especially after the consumption of water-soluble carbohydrates. As a result, the food pulp is rapidly released into the intestine shortly after ingestion, and water is increasingly passed into the intestine. This results in intensive and rapid absorption of the carbohydrates, causing the glucose serum level to rise rapidly above the norm. Insulin is increasingly secreted. After a short time, however, carbohydrate absorption ceases, resulting in an imbalance between the excess insulin and the now stagnant blood glucose (blood sugar) – due to the suspended carbohydrate absorption. Eventually, the serum glucose level drops below normal (hypoglycemia). Typical hypoglycemic symptoms are pallor, ravenous hunger, palpitations (palpitations), sweating, tachycardia (heartbeat too fast: > 100 beats per minute) and tremor (shaking).

Malnutrition (malnutrition) – inadequate coverage of energy and vital substance needs

The lack of reservoir function of the stomach results in inadequate nutrient utilization. Because of this, approximately 40% of all gastric resected patients are underweight. The cause of decreased nutrient utilization is insufficient stimulation of the pancreas, as the duodenum is not passed through by the food pulp in affected individuals. The rapid passage of large amounts of food pulp into the upper small intestine results in decreased secretion of digestive juices from the pancreas. Here, enzyme and bicarbonate secretion is reduced and the food pulp can be insufficiently mixed with bile and pancreatic juice. As a result of the unphysiological passage conditions as well as strain on the small intestine, small intestinal function is significantly impaired. For this reason, nutrients and vital substances cannot be sufficiently absorbed. The body is threatened with an undersupply of energy and a deficiency, especially of vitamin D and calcium. A frequently occurring secondary lactase deficiency, which underlies the unphysiological passage conditions, exacerbates the vitamin D and calcium deficits, since in this case those affected must largely avoid milk and dairy products. Depending on the degree of gastric mucosal loss due to gastric resection, a vitamin B12 deficit may also develop as a result of reduced intrinsic factor production. Inadequate secretion of digestive secretions from the pancreas is usually accompanied by higher-grade fat diarrhea. These can lead to high losses of fat-soluble vitamins – beta-carotene, vitamins A, D, E, K – as well as essential fatty acids. Furthermore, in partial or total gastric resection (stomach removal), insufficient appetite and an early onset of satiety are among the causes of inadequate coverage of energy and vital substance requirements. Vitamin D and calcium deficiency leads to parathyroid hyperfunction (hyperparathyroidism) and thus to increased production of parathyroid hormones. This secondary hyperparathyroidism presents with symptoms such as diarrhea (diarrhea), bloody stools, weight loss, rheumatic complaints, osteomalacia (softening of the bones), and decrease in bone substance (osteoporosis).

Reflux Esophagitis

50% of patients undergoing total gastric resection suffer from reflux esophagitis (inflammation of the esophagus caused by regular reflux (backflow) of acidic gastric juice into the esophagus). In this case, the lower sections of the esophagus are damaged by refluxing gastric juice. Reflux esophagitis presents with symptoms such as belching, difficulty swallowing, nausea, vomiting, and stomach pain and burning [4.1]. Affected individuals tend to suffer from malnutrition in these circumstances, which in turn is associated with inadequate nutrient and vital substance (macro- and micronutrient) intake.

Deficiency of intrinsic factor

Partial or total gastric resection (stomach removal) results in intrinsic factor provisioning problems because of the lack or absence of hydrochloric acid in the stomach. Due to the functional impairment of the gastric mucosa, the synthesis of intrinsic factor is disturbed. However, the glycoprotein is needed for the absorption of vitamin B12. If the intrinsic factor is missing in the stomach, vitamin B12 cannot bind to the glycoprotein and subsequently cannot be transported through the cell membrane into the blood and lymph channels.As a result of intrinsic factor deficiency, the intestinal-liver – enterohepatic circulation, which is essential for regulating vitamin B12 balance, is also interrupted. Accordingly, vitamin B12 can neither be converted in the intestine nor supplied to the liver. Patients undergoing gastric resection are therefore at increased risk of vitamin B12 deficiency.

Prognostic factors

  • R1 resection (macroscopically, the tumor was removed; however, histopathology shows smaller tumor components in the resection margin) → significantly worse long-term survivalConclusion: immediate resection!