FFinalistSouthampton · 2027
Gastroenterology
AKT · Gastroenterology/Oesophagus & stomach

Gastric cancer

Gastric adenocarcinoma (H. pylori, atrophic gastritis, diet, smoking)

Overview

Usually adenocarcinoma of the stomach, presenting late with dyspepsia, weight loss, early satiety and anaemia. Risk factors: H. pylori (intestinal-type via atrophic gastritis → intestinal metaplasia → dysplasia), pernicious anaemia, smoking, diet, family history (E-cadherin/CDH1 in diffuse type — linitis plastica). Diagnosed by endoscopy + biopsy; often advanced at presentation.

Recognise

  • New dyspepsia with weight loss, anorexia, early satiety, epigastric mass, iron-deficiency anaemia, vomiting (outlet obstruction)
  • Signs of metastasis: Virchow node (left supraclavicular — Troisier sign), Sister Mary Joseph nodule (umbilical), Krukenberg tumour (ovary), hepatomegaly, acanthosis nigricans (paraneoplastic)
  • Diffuse type (linitis plastica) — rigid 'leather-bottle' stomach; CDH1 hereditary diffuse gastric cancer

Red flags

  • Dyspepsia + ALARM features, or age ≥55 with weight loss + upper abdominal pain → urgent (2-week-wait) endoscopy
  • Virchow node / epigastric mass / persistent vomiting → advanced disease, urgent referral

Differentials & how to tell them apart

Peptic ulcer diseasebenign ulcer — but a gastric ulcer must be biopsied to exclude cancer
GORD/functional dyspepsiano ALARM features, normal endoscopy
Lymphoma (MALT)H. pylori-associated gastric lymphoma — may regress with eradication
Pancreatic cancerpainless jaundice/back pain, weight loss — different imaging

Investigations

Upper GI ENDOSCOPY + biopsy (diagnostic). Staging CT chest/abdomen/pelvis, endoscopic ultrasound, staging laparoscopy; FBC (anaemia), LFTs.

Management

Endoscopy + biopsy → gastrectomy + perioperative chemo (palliative if advanced)

  1. 1Urgent endoscopy + biopsy for ALARM/new dyspepsia with weight loss (≥55). Stage with CT/EUS/laparoscopy.Gate: A persistent GASTRIC ulcer must always be biopsied (and re-scoped) to exclude malignancy — do not treat as benign on appearance alone; Virchow node/mass signals advanced disease
  2. 2Resectable → gastrectomy + perioperative chemotherapy; advanced → palliative chemo ± trastuzumab (HER2+), best supportive care.
Surgery (gastrectomy) + perioperative chemotherapy — curative-intent for resectable disease
Palliative chemotherapy ± trastuzumab (HER2+) — advanced/metastatic disease

Key points

New dyspepsia + weight loss + anaemia in the older patient = urgent endoscopy. Troisier/Virchow node, linitis plastica (diffuse/CDH1), acanthosis nigricans (paraneoplastic — see endocrine). Biopsy every gastric ulcer.

Monitor & prognosis

Staging; post-treatment surveillance; B12 after gastrectomy.

Often late/poor; better if early/resectable.

Source: NICE NG12; BSG