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.
- Contrast CT chest, abdomen and pelvis is the first staging overview. Use EUS for selected local staging, PET-CT selectively because diffuse and mucinous disease may be non-avid, and laparoscopy for occult peritoneal spread before radical treatment.
- Staging laparoscopy with peritoneal cytology is a key reference step for potentially curable locally advanced gastric or junctional adenocarcinoma at peritoneal risk.
- Very early low-risk mucosal cancer can be treated by expert endoscopic submucosal dissection when pathological criteria for negligible nodal risk are met.
- Resectable disease usually receives perioperative chemotherapy and subtotal or total gastrectomy with an oncological D2 lymphadenectomy in a specialist centre.
- Do not equate D2 lymphadenectomy with routine removal of pancreas and spleen; preserve uninvolved organs to reduce morbidity.
- Advanced disease treatment depends on performance, HER2, PD-L1 and mismatch-repair or microsatellite status, prior treatment and the current funded indication.
- Outlet obstruction can be relieved by endoscopic stent or gastrojejunostomy according to fitness, anatomy and expected duration; nutrition and aspiration control begin immediately.
- After total gastrectomy, lifelong vitamin B12 replacement is required, with continuing iron, folate, calcium, vitamin D, bone and weight surveillance.
- Dumping improves with small frequent meals, separating drinks from meals and reducing rapidly absorbed carbohydrate; severe symptoms require specialist dietary and medical treatment.
- Eradicate H pylori when present and offer surveillance for appropriately staged extensive atrophy, metaplasia or hereditary risk through the dedicated premalignant pathway.
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.
Progressive early satiety, recurrent vomiting, succussion splash or dehydration suggests malignant gastric outlet obstruction.
Melaena, haematemesis, iron-deficiency anaemia, syncope or haemodynamic change indicates overt or occult tumour bleeding.
A rigid abdomen, severe sudden epigastric pain, fever or free air suggests perforation and needs immediate surgical care.
Virchow node, umbilical nodule, ascites, pelvic mass or peritoneal thickening suggests disseminated lymphatic or transcoelomic disease.
Rapidly progressive diffuse wall thickening with poor distension can be linitis plastica despite repeated superficial negative biopsies.
Shock, haematemesis, melaena or a rigid peritonitic abdomen requires immediate resuscitation and endoscopic or surgical source control.
Investigation priorities
Visualise and localise tumour, assess obstruction and obtain sufficient tissue for histology and biomarkers.
Stage gastric wall relationships, regional nodes, liver, lung, peritoneum and other distant disease and identify biopsy sites.
Management branches
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.
- Complete CT staging, pathology and dietetic assessment and refer to the specialist oesophago-gastric MDT rather than arranging isolated surgery from endoscopic appearance.