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Referral and warning signs
When to refer
Urgent referral for Endoscopy for patients with alarm features or persistent dyspepsia >40-55yrs. Refer ALL confirmed cases to specialized cancer centre.
Red flags
- Alarm features for dyspepsia (Weight loss, dysphagia, bleeding, anaemia, vomiting, mass)
- Palpable epigastric mass
- Signs of metastatic disease (jaundice, ascites, Virchow's node)
Signs and symptoms
- Often asymptomatic in early stages.
- Vague dyspeptic symptoms (epigastric pain/discomfort, bloating, early satiety) - persistent and non-responsive to usual treatment.
- Anorexia (loss of appetite).
- Unintentional weight loss.
- Nausea, vomiting (may indicate obstruction).
- Dysphagia (if tumour near gastro-oesophageal junction).
- Haematemesis ('coffee grounds' or fresh blood) or melaena (signs of GI bleeding).
- Iron deficiency anaemia (due to chronic occult bleeding).
- Palpable epigastric mass (late stage).
- Signs of metastatic disease: Ascites, Jaundice (liver mets), Palpable supraclavicular lymph node (Virchow's node), Periumbilical nodule (Sister Mary Joseph nodule), Palpable ovarian mass (Krukenberg tumour).
Risk factors
- Chronic Helicobacter pylori infection (major risk factor).
- Dietary factors: High intake of salted, smoked, pickled foods; low intake of fruits/vegetables.
- Smoking.
- Chronic atrophic gastritis / Intestinal metaplasia.
- Pernicious anaemia.
- Previous gastric surgery (e.g., partial gastrectomy).
- Genetic predisposition (e.g., hereditary diffuse gastric cancer - CDH1 mutation, Lynch syndrome).
- Family history of gastric cancer.
- Male gender.
- Blood group A.
Diagnosis
Clinical assessment
Suspect in older patients (>40-55) with new onset persistent dyspepsia, or any patient with alarm features (weight loss, dysphagia, bleeding, anaemia, vomiting, mass).
Investigations
- Upper GI Endoscopy (OGD) with multiple Biopsies: Essential for diagnosis. Allows visualization of lesion (ulcer, mass, thickened folds) and histological confirmation.
- H. pylori testing (biopsy or non-invasive).
- Staging Investigations: CT scan (Chest, Abdomen, Pelvis) - assess local extent, lymph nodes, distant metastases (liver, peritoneum, lungs). Endoscopic Ultrasound (EUS) - assess depth of tumour invasion (T stage) and regional nodes (N stage). Laparoscopy - assess for peritoneal metastases.
- Blood tests: CBC (anaemia), LFTs.
Diagnostic criteria
Histopathological confirmation from endoscopic biopsy.
Management
Non-pharmacological management
- Referral to specialized multidisciplinary team (Surgery, Oncology, Gastroenterology) at Cancer Centre.
- Management depends on stage.
- Curative Intent (Localized disease): Surgery (Gastrectomy - subtotal or total, with lymph node dissection) is the mainstay. Often combined with Perioperative Chemotherapy (pre- and post-operative) or Adjuvant Chemoradiotherapy.
- Palliative Intent (Metastatic or unresectable disease): Chemotherapy to control symptoms and prolong survival. Palliative surgery (e.g., bypass, stenting) for obstruction or bleeding. Palliative radiotherapy for pain/bleeding. Best supportive care.
- Nutritional support.
Pharmacological treatment
- Chemotherapy regimens (often platinum + fluoropyrimidine based, +/- targeted therapy).
- Targeted Therapy: Trastuzumab for HER2-positive advanced gastric cancer.
- Immunotherapy (e.g., PD-1 inhibitors) for specific subtypes/settings in advanced disease.
- H. pylori eradication (if positive, though role in established cancer debated).
- Pain management, antiemetics.
Monitoring
Monitor nutritional status, symptoms. Monitor treatment response/toxicity. Surveillance for recurrence after curative treatment (clinical exam, endoscopy, imaging as indicated).
Complications
- Bleeding
- Perforation
- Gastric outlet obstruction
- Malnutrition / Cachexia
- Metastatic disease
- Complications of surgery/chemo/radiation
Prevention
- Eradication of H. pylori infection.
- Dietary modifications (increase fruits/vegetables, reduce salt/smoked foods).
- Smoking cessation.
- Surveillance endoscopy for high-risk conditions (e.g., chronic atrophic gastritis, intestinal metaplasia).
Patient education
- Explain diagnosis, stage, and prognosis.
- Discuss treatment options (curative vs palliative).
- Explain surgery, chemotherapy, radiotherapy procedures and side effects.
- Nutritional advice.
- Importance of follow-up.
- Psychosocial support.
Uganda-specific notes
High prevalence of H. pylori infection contributes to burden. Often presents late. Access to endoscopy, pathology, staging (CT/EUS), surgery, chemotherapy, and targeted therapies limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 12, Section 12.3.2