Gastric Lymphoma Treatment

Gastric Lymphoma

Incidence of primary gastric lymphoma is increasing. They are B cell derived from mucosa-associated lymphoid tissue (MALT)—MALTOMA. Pain, weight loss, and bleeding are common presentations. 6th decade is the common age group.

• Endoscopic features are not specific but diffuse thickening with or without ulcerations may be seen.
• It is important to rule out generalised process by CT, ultrasound, bone marrow aspirate.
• Gastrectomy is the best treatment.
• Chemotherapy is better for systemic disease.

Complications Of Vagotomy And Gj

Complications Of Vagotomy And Gj: Can be classified as complications of vagotomy, complications of GJ and complications of gastrectomy.

1. Stasis of food in the stomach results in nausea, loss of appetite, distension of upper abdomen, foul eructation, etc.
2. Denervation of the gallbladder can cause gallstones.
3. Postvagotomy diarrhoea—can be very trouble¬some at times.
4. Vagotomy produces hypoacidity which allows bacterial proliferation. Nitrates are reduced to nitrites which are carcinogenic. Such a malignancy which develops at GJ site is called stump carcinoma.

Gastrointestinal Stromal Tumours Causes of Diarrhoea

• Vagotomy results in removal of parasympathetic influence on the function of foregut and midgut.
• Fast gastric emptying occurring due to GJ or gastrectomy.
• Hypoacidity resulting in bacterial proliferation causing enteritis.
• Bile salts also play a role.

1. Stomal Obstruction: It is due to oedema as in gastroduodenal anastomosis or nondependent drainage as in GJ. Sometimes, fat in the transverse mesocolon undergoes necrosis resulting in obstruction to the loops. Stomal obstruction also develops, if there is narrowing of the lumen. Treatment is conservative. Surgery may also be required later, after confirming obstruction by gastrografin studies.

2. Retrograde Jejunogastric Intussusception: It develops if efferent and afferent loops are not sutured properly. It can appear at any time after surgery.

Retrograde Jejunogastric Intussusception Clinical Features

• Previous history of abdominal surgery (surgery done for peptic ulcer)
• Acute abdominal pain in upper abdomen
• Vomiting, sometimes blood stained
• Palpable mass in the upper abdomen.

Retrograde Jejunogastric Intussusception Investigation: Barium meal X-ray shows filling defect in the stomach. Sometimes, following a barium meal, intussusception is reduced.

Retrograde Jejunogastric Intussusception Treatment: Reduction of the intussusception and suturing of intestinal loops properly. If the loops are gangrenous, resection may be necessary.

Retrograde Jejunogastric Intussusception Complication: Gangrene of intestine.

3. Gastrojejunocolic Fistula

• It is a complication of GJ done for peptic ulcers, especially when vagotomy is not done or is incomplete.
• After a few years of GJ, a recurrent ulcer can develop at the stoma—GJ site.
• This recurrent ulcer slowly invades the adjacent structure such as the transverse colon resulting in gastrojejunocolic fistula.

Gastrojejunocolic Fistula Clinical Features

• Previous history of vagotomy and GJ.
• Foul eructation and foul vomiting due to colonic contents entering the stomach which is loaded with faecal matter and foul contents.
• Intense diarrhoea due to severe jejunitis brought about by colonic bacteria entering the jejunum.
• Rapid deterioration in health—loss of weight, loss of appetite, dehydration and emaciation.
• Diarrhoea is not due to food entering the colon. Contents of the colon enter the stomach and then jejunum resulting in jejunitis causing diarrhoea.

Gastrojejunocolic Fistula Diagnosis: Confirm by barium enema—barium entering the stomach (because of high pressure in the colon). Barium meal study should not be done.

Gastrojejunocolic Fistula Treatment

• Triple resection.
• Preoperative preparation is necessary in the form of blood transfusion, stomach wash, nutritional supplementation and correction of dehydration.
• Resection of portions of stomach, intestine and colon followed by end-to-end anastomosis.

4. Stump Carcinoma: It refers to carcinoma developing in the stomach after some surgery on the stomach. Classically, it happens after a gastrojejunostomy (GJ) Billroth II or after a pyloroplasty.

• It develops after 10 to 20 years of surgery.
• Reflux of bile, changes in the acidity due to vagotomy are a few factors that precipitate stump carcinoma. Metaplasia is due to enterogastric reflux and bacterial reduction of nitrates.
• Clinical features include sudden loss of appetite, loss of weight with or without mass abdomen.
• Diagnosis is by endoscopy.
• Treated by resection. However, many cases are advanced and they are inoperable.

5. Gastroileostomy 

• It is an avoidable complication.
• Instead of the short loop—jejunum, ileum is anastomosed to the stomach.
• There will be severe uncontrolled diarrhoea, loss of weight and emaciation within a short period.
• Barium meal with fluoroscopy should be done which shows rapid flow of barium from stomach into the ileum.
• Laparotomy—undoing of gastroileostomy and fresh gastrojejunostomy should be done.

6. Postcibal Syndromes: This syndrome complex results due to rapid emptying of stomach contents to the distal intestines resulting in various physiological changes such as vasomotor symptoms, hypoglycaemia, etc. They are of two types. Their comparison is given in Table.

Complication Of Gastrectomy

1. Nutritional Disturbances

• Vitamin B 12 and calcium deficiency.
• Megaloblastic anaemia occurs late due to gastric mucosal atrophy.
  
• Iron deficiency anaemia, common after gastrectomy when duodenum is bypassed because of deficient iron absorption.
• Diarrhoea is due to vagotomy causing intestinal hurry or due to dumping.
• Due to poor nutrition, there is weight loss and they are susceptible for pulmonary tuberculosis.

2. Duodenal Fistula (Duodenal Blow Out): It is the leakage of duodenal contents to the exterior. It
commonly occurs after surgery.

Duodenal Fistula Causes

• After a partial gastrectomy/total gastrectomy, where the closure of duodenum was difficult.
• After closure of the perforated duodenal ulcer, which gives way once again.
• Injuries to duodenum during right hemicolectomy, right nephrectomy, etc.

Duodenal Fistula Precipitating Factors

• Faulty technique of closure of duodenal stump.
• Severely inflamed duodenum due to an active ulcer.
• If there is a distal obstruction, it increases tension in duodenal loop and may result in fistula.
• Ischaemia of duodenal stump.

Duodenal Fistula Clinical Features

• Signs and symptoms develop usually after 4 to 5 days when oral fluids are commenced. These stimulate an outpouring of biliary and pancreatic juices.
• Severe upper abdominal pain and guarding, rigidity, hypotension and shock-like features of biliary peritonitis develop if there is no drainage tube.
• If the drainage tube is kept in the first surgery, bile flows to the exterior. In such cases, signs of peritonitis are usually not present. However, severe electrolyte imbalance can occur.

Duodenal Fistula Treatment

• Conservative treatment is successful in majority of the cases. Fistula heals in a few days, provided there is no distal obstruction. During this time hydration, electrolyte care is essential. Appropriate antibiotics are given.
• Surgical—if the fistula persists, laparotomy and closure of the fistula can be done by repairing with nonabsorbable sutures.

Duodenal Fistula Complications

• Biliary peritonitis
• Septicaemia, if bile is not drained outside.
• Excoriation of abdominal skin can be prevented by zinc oxide application.
• Fluid and electrolyte imbalance.

3. Recurrent Ulcer: It can be true anastomotic ulcer (gastrojejunal, gastro-duodenal or jejunal ulcer), or a gastric ulcer in the remnant, or recurrent ulcer following highly selective vagotomy (HSV).

Recurrent Ulcer Incidence

• 3% after Billroth II gastrectomy
• 5 to 8% after vagotomy and GJ
• 40% after gastrojejunostomy
• 10 to 12% following HSV.

Causes of Recurrent Ulcer

1. Incomplete vagotomy
2. GJ alone
3. Inadequate gastrectomy
4. Narrow stoma
5. Zollinger-Ellison syndrome
6. Hyperparathyroidism

Recurrent Ulcer Symptoms

• Appears within 1 to 2 years after the operation.
• Severe persistent pain, ‘boring’ type, which gets worse within a few minutes of taking food. The pain is felt on the left side of the abdomen, near the umbilical region and it passes downwards.
• The pain is felt in the lower left chest following antecolic anastomosis. It is not relieved by antacids or milk unlike peptic ulcer. Bleeding may manifest as haematemesis, melaena or anaemia. Perforation can occur, resulting in peritonitis.

Recurrent Ulcer Diagnosis

• Gastroscopy gives the correct diagnosis.
• Hypercalcaemia and hypergastrinaemia should be ruled out.

Recurrent Ulcer Management

• Conservative treatment with H₂ receptor blockers is nearly always effective but relapse occurs, if they are stopped. Smoking should be stopped.
• However, definitive surgery is indicated in appropriate cases.

Acute Dilatation Of Stomach

Acute Dilatation Of Stomach Aetiopathogenesis

1. Can occur after any operation, particularly splenectomy and pelvic procedures.
2. It can occur following fracture femur, application of plaster of Paris, etc. Malnutrition, excessive distension of the stomach due to ventilation, and aerophagia are other precipitating factors.

There is a sudden loss of sympathetic tone resulting in massive dilatation of the stomach. Improper Ryle’s tube aspiration and permitting intake of oral fluids too early before paralytic ileus settles down are additional factors.

Acute Dilatation Of Stomach Clinical Features

• History of surgery.
• Hiccoughs—due to irritation of under surface of the diaphragm, by the hugely distended stomach.
• Abdominal pain, vomiting, distension. Vomiting contains foul-smelling dirty fluid and blood and is effortless.
• Effortless vomiting of litres of dark watery fluid is characteristic of this condition.

Acute Dilatation Of Stomach Treatment: Urgent Resuscitation

• Introduce a Ryle’s tube and aspirate the stomach. It is the life-saving use of Ryle’s tube.
• Rapid 4 fluid replacement, with normal saline and dextrose saline. Both crystalloids and colloids may be necessary to treat the shock and electrolyte abnormalities.

Acute Dilatation Of Stomach Complications

• Pulmonary: In debilitated patients, aspiration may result in aspiration pneumonitis (Mendelson syndrome).
• It carries significant mortality.

Volvulus Of The Stomach

It is a rare condition in which the stomach rotates in a horizontal (organoaxial) and vertical (mesentericoaxial) direction resulting in an acute abdomen. Organoaxial is more common. Many times, volvulus is intermittent. In general, initially, the colon moves upwards and later greater curvature of the stomach.

• There is associated eventration of the diaphragm which also precipitates this condition (in children, congenital).
• In adults, diaphragmatic defects are more commonly traumatic or para-esophageal herniation.
• Clinical features include epigastric pain, fullness and tenderness.

Volvulus Of The Stomach Borchardt’s Triad

1. Sudden, constant, severe upper abdominal pain
2. Recurrent retching with production of little vomitus
3. Inability to pass a nasogastric tube.

Volvulus Of The Stomach Diagnosis

• Plain X-ray abdomen/chest: Gas-filled viscus.
• Barium meal can demonstrate twisted stomach.
• Upper GI scopy.

Volvulus Of The Stomach Treatment

• Reduce the volvulus by dividing gastrocolic omentum
• Fix the greater curvature of the stomach to the duo¬denojejunal flexure or perform a GJ without stoma.
• Repair of eventration
• Fixing by tube gastrostomy can also be done.