Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Bleeding, perforation or gastric outlet obstruction
Haemodynamic upper-GI bleeding, sudden peritonitic pain with free perforation, persistent vomiting with severe electrolyte depletion or aspiration from malignant outlet obstruction requires immediate resuscitation and source control.
Action: Use ABCDE care, activate the upper-GI bleed or perforation pathway, keep nil by mouth, obtain large-bore access, bloods and crossmatch, give fluids and blood products and urgent antibiotics for perforation and involve endoscopy, surgery, interventional radiology and oncology for haemostasis, drainage, resection, bypass or stenting.
Synopsis
Recognise gastric malignancy and its emergencies, obtain high-quality endoscopic histology, detect occult peritoneal disease before radical surgery and integrate endoscopic, perioperative, surgical, biomarker-directed, nutritional and palliative care.
Gastric adenocarcinoma often presents late with weight loss, epigastric discomfort, early satiety, anaemia or vomiting; a normal abdominal examination does not exclude it.
First-line diagnosis is high-quality upper-GI endoscopy with at least six biopsies from a suspicious lesion and separate mapping when premalignant background or linitis is considered.
Repeat deeper or bite-on-bite sampling, EUS-guided core or laparoscopic tissue when diffuse infiltrative cancer is suspected despite superficial non-diagnostic biopsies.
Key red flags
Unintentional weight loss with upper abdominal pain, reflux, dyspepsia or nausea requires urgent upper-GI cancer assessment under the age- and feature-specific pathway.
Major haemorrhage or perforation
Shock, haematemesis, melaena or a rigid peritonitic abdomen requires immediate resuscitation and endoscopic or surgical source control.
Investigation priorities
01
First-line upper-GI endoscopy with multiple biopsiesFirst stepFirst line
Visualise and localise tumour, assess obstruction and obtain sufficient tissue for histology and biomarkers.
02
First-line contrast CT chest abdomen and pelvisFirst line
Stage gastric wall relationships, regional nodes, liver, lung, peritoneum and other distant disease and identify biopsy sites.
Management branches
Suspected cancerEndoscope and biopsy without delay
Alarm dyspepsia, weight loss, anaemia, vomiting, early satiety or bleeding suggests a gastric lesion.
Assess bleeding, obstruction, perforation, hydration, aspiration and nutrition and stabilise emergencies before or alongside urgent endoscopy.
Perform a complete high-quality examination with multiple targeted biopsies and obtain deeper or image-guided tissue if diffuse infiltration, lymphoma or subepithelial tumour remains possible.
Key medicines
FLOT perioperative chemotherapyEvery 2 weeks, a specialist FLOT cycle commonly uses intravenous docetaxel 50 mg/m², oxaliplatin 85 mg/m² and leucovorin 200 mg/m² followed by fluorouracil 2,600 mg/m² over 24 hours, usually for four preoperative and four postoperative cycles.
Trastuzumab for HER2-positive advanced adenocarcinomaA standard three-weekly intravenous schedule uses trastuzumab 8 mg/kg as a loading dose then 6 mg/kg every 3 weeks with the selected fluoropyrimidine and platinum regimen under the licensed indication.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.