1.A friend of mine developed a complication called “dumping syndrome” after gastric surgery, what is “dumping syndrome”?
Dumping syndrome is a group of syndromes that occur after gastric resection due to rapid gastric emptying and postprandial gastrointestinal and vasodilatory disorders, and may also be due to hyperinsulinemia caused by stimulation of the pancreatic islets, resulting in hypoglycemic syndrome. This syndrome is most common after major gastrectomy with Billroth (Billroth) type II. The onset of symptoms within 30 minutes after a meal is called early dumping syndrome, which is also called early postprandial hyperglycemic syndrome. The onset of symptoms 1 to 2 hours after a meal, accompanied by hypoglycemia, is called late dumping syndrome, also known as postprandial hypoglycemia syndrome. Early dumping syndrome is mainly due to the rapid increase of hyperosmolar food in the small intestine and the expansion of jejunum, the decrease of blood volume due to the migration of plasma from blood vessels to jejunum, and the release of 5-hydroxytryptamine and bradykinin from intestinal mucosa and the dysfunction of vegetative nervous system. Late dumping syndrome is caused by the increase of carbohydrates in the intestine and the release of intestinal hyperglycemic hormone, which makes the pancreatic β cells secrete excessive insulin, resulting in hypoglycemic reaction after hyperglycemia.
2.What are the manifestations of dumping syndrome? How to treat dumping syndrome?
The manifestations include epigastric fullness, spasmodic abdominal pain, nausea, vomiting, abdominal rumbling, belching followed by diarrhea; and symptoms of vasodilator disorder such as palpitations, vertigo, headache, pallor, dry mouth and sweating, postural hypotension, etc. Late dumping syndrome mainly manifests as hypoglycemic syndrome, such as vertigo, weakness, palpitations, excessive sweating, epigastric empty hunger, anxiety, nervousness, etc.
The treatment is mainly dietary management, small and frequent meals, solid food, limiting sugar food intake, high protein and high fat food, slow eating and lying down for half an hour after meals. The symptoms can be reduced by taking less sugar water in case of late onset. For those who are not effective in medical treatment, Billroth II gastrectomy can also be changed to I through surgery, which can improve the symptoms significantly.
3.What is gastric mucosal prolapse?
Prolapse of gastric mucosa is caused by the retrograde protrusion of abnormally loose gastric mucosa into the esophagus through the cardia or prolapse into the duodenal bulb through the pyloric duct in a prograde manner, the latter being more common clinically. The occurrence of gastric mucosal prolapse is mainly related to inflammation of the gastric sinus, and gastric mucosal prolapse can also occur with malignant cell infiltration of the gastric mucosa. When the gastric sinus is inflamed, the submucosal connective tissue is looser, the gastric mucosa and submucosal layer are proliferated, and if the peristalsis of the gastric sinus is enhanced, the mucosal folds are easily sent to the pylorus, forming gastric mucosal prolapse. All factors that can cause vigorous gastric peristalsis, such as mental tension, tobacco, alcohol, coffee stimulation, etc. are the triggers of gastric mucosal prolapse. Gastric mucosal prolapse often coexists with inflammation of the stomach and duodenum, but the relationship between them needs further study.
4.What are the manifestations of gastric mucosal prolapse?
Gastric mucosal prolapse is mostly seen in men aged 30-60 years. Patients with mild cases may be asymptomatic or have only non-specific symptoms such as abdominal distension and belching. Some patients with gastric mucosa prolapse into the pylorus and cannot be reset immediately may have vague pain, burning pain or even colic in the upper and middle abdomen, which may radiate to the back, often accompanied by nausea and vomiting. The appearance of symptoms is often related to the patient’s body position. For example, it tends to occur in the right lateral recumbent position and less frequently or even not in the left lateral recumbent position. Because eating can promote gastric peristalsis and facilitate the occurrence of gastric mucosal prolapse, the symptoms are often related to eating, but lack obvious periodicity and rhythmicity. The pain can sometimes be relieved by alkaline drugs, but the effect is much less pronounced than that of peptic ulcer. Epigastric pressure may be the only positive sign of gastric mucosal prolapse. When the prolapsed mucosa obstructs the pyloric canal and becomes lodged or strangulated, a soft, painful mass may be felt in the upper abdomen, and symptoms of pyloric obstruction, with or without gastrointestinal bleeding, may be present. Some patients have a positive fecal occult blood test. The mucosa of the gastric sinus is normal or congested and edematous during gastroscopy; sometimes bleeding spots, erosions or superficial ulcers can be seen; when the gastric sinus is contracted, the gastric mucosa enters the duodenum via the pylorus with peristalsis, and during diastole, the prolapsed mucosa of the gastric sinus can return to the gastric cavity from below the pylorus. barium X-ray gastrointestinal meal examination has a definite diagnostic value. When the patient is in prone position and right lateral position, a variable central filling defect at the bottom of the duodenal bulb can be seen, and in typical cases, the pyloric canal is widened and the gastric mucosal folds enter the duodenal bulb through the pyloric canal, making the duodenal bulb “myxoid” or “parachute” shaped deformation (see figure below). deformation (see the figure below).
The arrow points to the “myxoid” deformation of the bottom of the duodenal bulb
5.What are the treatments for gastric mucosal prolapse?
Gastric mucosal prolapse is mainly treated by internal medicine, but there is no special medicine available. General treatment includes a small number of meals, abstaining from smoking and alcohol, giving sedatives and anticholinergic drugs, etc. Those with pyloric obstruction or gastrointestinal bleeding should be treated accordingly. In case of pyloric obstruction caused by gastric mucosal prolapse or complicated by massive gastrointestinal bleeding, surgical treatment is often required.
6.Is the incidence of gastric cancer high?
Gastric cancer is a malignant tumor originated from epithelial cells of gastric mucosa, accounting for 95% of gastric malignant tumors. The incidence rate of gastric cancer is very high in China, and the mortality rate is the first among malignant tumors. The average mortality rate of gastric cancer is as high as 20/100,000 nationwide, and the ratio of male to female is higher than that of female, and the peak age of incidence is 50-60 years old. The annual incidence rate of gastric cancer in the world is 17.6/100,000, with high incidence rates in Japan, Chile, Iceland, Austria, Finland, Hungary, etc., and low incidence rates in North America, India, Indonesia, Malaysia, Egypt, etc. In China, Gansu Hexi Corridor, Jiaodong Peninsula and coastal areas of Jiangsu and Zhejiang are the high incidence areas. The incidence rates of different regions in the same country can be significantly different, and there are low incidence points in high incidence areas and high incidence points in low incidence areas.
7.What are the manifestations of gastric cancer?
(a) Symptoms: More than 70% of early gastric cancer can be asymptomatic. According to the mechanism of occurrence, the symptoms of late gastric cancer can be divided into 4 aspects.
(1) Energy consumption and metabolic disorders due to cancer proliferation, resulting in low resistance, malnutrition, vitamin deficiency, etc., manifested as weakness, loss of appetite, nausea, emaciation, anemia, edema, fever, constipation, dry skin and hair loss, etc.
(2) Upper abdominal pain, gastrointestinal bleeding and perforation caused by ulceration of gastric cancer. The pain of gastric cancer is often biting, not clearly related to eating or aggravated after eating. Some of them resemble the pain of peptic ulcer, which can be relieved by eating or antacids, and this condition can be maintained for a long time, and then the pain gradually increases and persists. When the cancer bleeds, it is manifested as positive fecal occult blood test, vomiting blood or black feces. 5% of patients have heavy bleeding, and there are even those who seek medical attention for the first time due to bleeding or acute abdomen such as gastric cancer perforation.
(3) Symptoms caused by mechanical effects of gastric cancer, such as feeling of fullness and heaviness due to poor gastric filling, as well as tastelessness, anorexia, pain, nausea, vomiting, etc. Gastric cancer located near the cardia can invade the esophagus, causing eructation and difficulty in swallowing, and located near the pylorus can cause pyloric obstruction.
(4) Symptoms caused by metastasis of cancer, such as ascites, hepatomegaly, jaundice and metastasis of lung, brain, heart, prostate, ovary, bone marrow, etc., which cause corresponding symptoms.
(2) Physical signs: early stage gastric cancer may have no physical signs, while the upper abdominal pressure pain is the most common among the physical signs of middle and late stage cancer. 1/3 patients may find an abdominal mass with firm and irregular quality and may have pressure pain. Whether the abdominal mass can be found or not is related to the location, size and thickness of the abdominal wall of the patient. More patients can find abdominal masses in gastric sinus cancer. Other signs are mostly produced by advanced or metastatic gastric cancer, such as enlarged, hard, irregular surface liver, jaundice, ascites, and enlarged left supraclavicular and left axillary lymph nodes. In men, a hard mass may be found in the upper part of the prostate on rectal examination, and in women, an enlarged ovary may be found on vaginal examination. Other rare signs include nodules on the skin and abdominal white line, enlarged inguinal lymph nodes, fever in advanced stage, and malignant quality. In addition, the paraneoplastic syndrome of gastric cancer including thrombophlebitis, acanthosis nigricans and dermatomyositis may also have corresponding signs.
8.How to detect early gastric cancer?
The most common symptom of early gastric cancer is upper abdominal discomfort, such as mild stomach pain, swelling and heaviness, and sometimes vague pain in the heart fossa, which is often diagnosed as gastritis or ulcer disease and treated, and the symptoms may be temporarily relieved. If the lesion occurs in the gastric sinus, duodenal function may change and rhythmic pain may occur, similar to the symptoms of ulcer disease, which may also be misdiagnosed as duodenal ulcer and delay treatment, and these symptoms may recur after a period of time. Therefore, anyone who has symptoms of epigastric discomfort, if accompanied by other high-risk factors, or who has recurrent recurrences after treatment, must be vigilant and undergo further investigations for early detection and treatment.
Indigestion symptoms such as loss of appetite, anorexia and poor appetite, nausea and vomiting, bloating after eating, belching and acid reflux are also a group of common but non-specific early signs of gastric cancer. Loss of appetite may be an early symptom of gastric cancer and is not accompanied by symptoms of stomach pain, especially if it occurs simultaneously with stomach pain and hepatitis can be excluded. Some patients automatically restrict their daily diet because of bloating and belching after eating, resulting in weight loss, emaciation and weakness. Early symptoms of gastric cancer may also include a feeling of fullness after eating and mild nausea. Tumor in the cardia may start with eating disorder and gradually develop into swallowing difficulty and food reflux. Further development of sinus cancer may lead to vomiting due to pyloric obstruction.
The above symptoms can be easily mistaken for functional dyspepsia, so one should seek early medical attention and undergo gastroscopy and other examinations in order to detect gastric cancer at an early stage.
Both early gastric cancer and progressive gastric cancer can present with upper gastrointestinal bleeding, often in black stools. A small number of early gastric cancers may show mild upper gastrointestinal bleeding symptoms, i.e. black stool or persistent positive occult blood in stool. It is mostly seen in polyp-like and ulcer-like early gastric cancer, which is caused by surface erosion of the lesion or invasion of capillaries by the cancer, resulting in long-term small amount of bleeding. It is not easily controlled by drug therapy. Any elderly people without gastric disease should be more alert to the possibility of gastric cancer once black stool appears, such as tarry stool and persistent positive stool occult blood test, especially when it is not easy to stop even after general diet control or taking gastric medicine, which is one of the important early gastric cancer symptoms. Therefore, those who have such symptoms should go to a hospital in time for gastroscopy and upper gastrointestinal barium meal X-ray to make a clear diagnosis.
Lethargy, weakness and mental depression with clear reasons are also common but unspecific signs of gastric cancer, and they are progressively worsening. Some of them are secondary to dyspepsia, and patients automatically restrict their daily diet due to bloating and belching after eating, resulting in weight loss and then emaciation and weakness. In addition, nausea and vomiting can further lose nutrition and cause malnutrition, which will aggravate the symptoms of emaciation and weakness. Of course, in the late stage of progressive gastric cancer, the wasting and weakness will be more obvious.
In addition, it is worth mentioning that pathologically most gastric cancers occur on the basis of chronic gastritis (especially atrophic gastritis), Helicobacter pylori (HP) infection, residual gastritis, gastric polyps, gastric ulcer, etc. Therefore, some patients have a long history of chronic gastric disease, with symptoms such as epigastric discomfort and indigestion. On this basis, if the nature of pain, epigastric fullness, etc. has changed or the degree has increased recently, the pain rhythm related to diet has changed, or cannot be relieved after taking medication, or there is wasting and weakness, etc., then it is more important to be alert to the occurrence of cancerous changes.
Most of the gastric cancer patients with emaciation and weakness are progressive gastric cancer, and most of them have local or distant metastasis, and often have anemia.
Various etiologies can cause vomiting, such as common duodenal bulb ulcer or post-ulcerative scar stenosis, reflux esophagitis, cardia ulcer, etc. Emesis can also be caused by pancreatic cancer or gastric cancer involving the pylorus, and vomiting can include decaying food, gastric juice, or even coffee-like bloody fluid. Vomiting is usually a clinical manifestation of progressive gastric cancer, often accompanied by emaciation.
The painless, hard and fixed swollen lymph node like soybean or peanut on the left clavicle is a more specific sign of gastric cancer, which is mostly a sign of progressive gastric cancer with metastasis to abdominal cavity and other organs.
Once the enlarged left supraclavicular lymph node is found, lymph node biopsy or cytological aspiration should be done immediately; gastroscopy and biopsy of gastric cancer lesions in multiple pieces and directions should be taken for pathological examination, supplemented by barium gastric X-ray if necessary, to make a clear diagnosis immediately.
Men over 50 years old who suffer from gastric disease should be alerted and have relevant special examinations as early as possible if they have recurrent epigastric pains that come and go recently. At present, the commonly used tests are fiberoptic gastroscopy and barium X-ray fluoroscopy. Gastroscopy can not only directly observe the morphology, color and lesions of gastric mucosa, but also remove suspicious cellular tissues for pathological examination by gastroscopic forceps. x-ray barium meal gas-barium double contrast imaging examination has no contraindications and side effects. In addition, gastric fluid examination and fecal occult blood test can be used as auxiliary diagnostic tools.
Japan is also a country with a high incidence of gastric cancer. Japan is internationally recognized as a world leader in the diagnosis rate, treatment efficiency and survival time of gastric cancer patients, which is mainly due to the popularity of gastroscopy and the use of gastroscopy for gastric cancer screening, so its detection rate of early gastric cancer is significantly higher than that of other countries. The treatment effect of early-stage gastric cancer is far better than that of progressive gastric cancer. Therefore, the foundation of “three early stages” of cancer prevention and treatment: early detection, early diagnosis and early treatment, lies in early detection and early diagnosis, otherwise early treatment is impossible, let alone achieving good curative effect. The early detection of the “three early” is for the general population, people should pay attention to their own health, timely detection of problems, and then seek help from medical workers to create opportunities for early diagnosis. Therefore, if possible, it is a very necessary health investment for people to have a systematic health checkup once a year after they are over 35 years old.
9.What factors are related to gastric cancer?
At present, the following factors are considered to be related to the occurrence of gastric cancer.
(a) Different environmental factors: The obvious difference in incidence rate between countries and regions indicates that it is related to environmental factors, the most important of which is dietary factors. Salt may be one of the exogenous gastric cancer predisposing factors, and the incidence of gastric cancer is also high in countries where residents consume more salt. Nitrosamines have been successful in inducing gastric cancer in animals. Smoked fish contains more 3,4-benzopyrene (benzopyrene); moldy food contains more fungal toxins; rice is covered with talc after processing, and its chemical properties and structure are similar to asbestos fibers, all the above substances are considered to have possible carcinogenic effects.
(B) Genetic factors: The incidence of gastric cancer is higher in certain families. Some data show that stomach cancer occurs more often in people with blood type A than those with blood type O.
(iii) Immune factors: The incidence of gastric cancer is higher in people with low immune function. It is possible that when the immune function of the body is impaired, the immune supervision of the body against cancer decreases, which may have some significance in the occurrence of gastric cancer.
(iv) Pre-cancerous changes: The so-called pre-cancerous changes refer to certain lesions with strong tendency of malignancy, which may develop into gastric cancer if left untreated. Pre-cancerous changes include precancerous conditions and precancerous lesions.
Pre-cancerous conditions of the stomach include
(1) Chronic atrophic gastritis: there is a significant positive correlation between chronic atrophic gastritis and the incidence of gastric cancer.
(2) Pernicious anemia: gastric cancer occurs in 10% of patients with pernicious anemia, and the incidence of gastric cancer is 5 to 10 times higher than that of the normal population.
(3) Gastric polyps: Although adenomatous or villous polyps do not account for a high proportion of gastric polyps, the cancer rate is 15% to 40%, and the cancer rate is higher for those with a diameter greater than 2 cm. Gastric hyperplastic polyps are common, while the cancer rate is only 1%.
(4) Stomach remnant: the cancer that occurs in the stomach after surgery for benign gastric lesions is called gastric remnant cancer. The incidence increases significantly after gastric surgery, especially from 10 years after surgery.
(5) Benign gastric ulcer: gastric ulcer itself is not a pre-cancerous state, while the mucosa at the edge of the ulcer is prone to intestinal epithelial metaplasia and malignancy.
(6) Giant gastric mucosal fold disease (Menetrier’s disease): serum protein is lost through giant gastric mucosal fold, with clinical hypoproteinemia and swelling, and about 10% may become cancerous.
Pre-cancerous lesions of the stomach
(1) Anaplastic hyperplasia and interstitial lesions: the former is also called atypical hyperplasia, which is a reversible pathological cellular proliferation caused by chronic inflammation and may not be cancerous in a few cases. Interstitial gastric metaplasia (anaplasia) has more chances of carcinogenesis.
(2) Intestinal metaplasia of gastric mucosa: there are two types: small intestine type and large intestine type, small intestine type (complete type) has the characteristics of small intestine mucosa and is better differentiated. The large intestine type (incomplete type) is similar to large intestine mucosa and can be divided into two subtypes: type IIa, which can secrete non-sulfated mucin; type IIb, which can secrete sulfated mucin, and this type is closely related to the occurrence of gastric cancer.
10.What examinations should be done for gastric cancer?
In addition to careful medical history and physical examination, patients suspected of gastric cancer usually have the following examinations. Some laboratory examinations include examination of gastric juice, blood sampling for routine blood tests, biochemical liver and kidney functions, routine stool examination for occult blood and immunological examinations such as CEA, FSA, GCA, YM globulin, etc. X-ray examination is an important non-invasive examination for gastric cancer patients, including dual gas-barium imaging, etc. These examinations are very important. Fiberoptic endoscopy is gastroscopy, which is the most direct, accurate and effective diagnostic method to diagnose gastric cancer. In addition, there are also exfoliative cytology examination, ultrasound and CT examination, etc. The examination items may be a little different from one hospital to another.
The above picture is X-ray examination showing ulcerative gastric cancer of the gastric sinus
The above picture is early bulging gastric cancer seen under gastroscopy