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Dietary treatment for peptic ulcer of the stomach and duodenum is based on the principle of exposure to:
a) the clinical manifestations of the disease;
b) impaired metabolism; c) other regulatory systems. Clinical nutrition should be based not only on clinical symptoms, but also on the characteristics of the metabolic processes in the patient’s body, for which it is necessary to provide the body with indispensable nutritional factors, in particular amino acids, essential fatty acids, and vitamins. The correct rhythm of nutrition is of great importance. A meal is recommended every 3-4 hours, in small portions. Exclude too hot and cold food. To relieve the inflammatory process in the gastroduodenal the system limit table salt to 10-12 g per day.
When building diets, the effect of food on the secretory and motor functions of the stomach is taken into account.
All nutrients can be divided into weak and strong pathogens of gastric secretion. Weak pathogens of gastric secretion: milk, cereal or vegetable soups (from potatoes, carrots and beets); liquid milk porridges; well-boiled meat and fresh boiled fish; milk and dairy products; soft-boiled eggs or as an omelet; yesterday’s white bread; alkaline waters that do not contain carbon dioxide; weak tea. Strong secretion pathogens include: spices (mustard, cinnamon, horseradish, etc.); all dishes of plant and animal origin prepared by frying; canned food; all dishes containing extractive substances (for example, meat, fish, mushroom broths; strong navar from vegetables); black bread; strong tea, coffee; drinks containing alcohol and carbon dioxide.
However, the same product, prepared in different ways, presents a completely different burden for the stomach; a piece of fried meat is a strong causative agent of gastric secretion, and boiled meat causes a slight excitation of the secretory process. Fat, for example, has a
biphasic action, ou suppresses secretion followed by saponification products of fat in the intestine to stimulate it.
The consistency of impoverishment also affects the secretion of gastric juice. So, a piece of meat is longer in the stomach than a meat souffle. Liquid and mushy foods leave the stomach faster than solid foods. The chemical composition of food is also essential. Carbohydrates leave the stomach quickly, proteins more slowly and fats remain in it for the longest time.
The longer the food is in the stomach, the more it irritates the mucous membrane and increases its secretory function.
The diet should not include products that mechanically irritate the gastric mucosa, containing coarse cell membranes (turnip, radish, radish, asparagus, beans, peas); unripe and rough-skinned fruits and berries (gooseberries, currants, grapes, dates); bread made from wholemeal flour; products containing coarse connective tissue (cartilage, skin of poultry and fish, sinewy meat). When building sparing diets, food substances are prescribed that weakly excite secretion, quickly leave the stomach and slightly irritate its mucous membrane.
Under the influence of sparing diets, as a rule, all clinical manifestations of the disease disappear. By changing the chemical composition of the diet, it is possible to influence a metabolic disorder, stimulate the healing of a ulcer defect, and influence the regulatory function of the nervous system. The antiulcer diet should be complete, balanced in terms of protein, fat, carbohydrate, mineral salts and vitamins (mainly C, D1 and A). Proteins included in the diet should contain all the necessary amino acids in optimal proportions. This is done by introducing into the diet a variety of products of both animal and plant origin. Antiulcer diets are enriched with vegetable oils by reducing animal fat. Vegetable fats are administered in an amount of 1/3 of the total fat content in the diet. Vegetable oils are added to cereals, soups and fish products. This normalizes disturbed metabolic processes in patients with peptic ulcer disease and promotes ulcer healing. The diet includes homogenized vegetables (mashed beets, carrots, pumpkins). They are added to mucous soups, mashed cereals and other dishes. The use of homogenized vegetable purees can significantly improve the appearance of food, increase the taste and nutritional value of dishes.
Of sufficient importance is the sufficient content in the diets of mineral salts and vitamins. Vitamin C is the most; contained in rose hips, so it is advisable that the patient receives a rosehip decoction daily. Vitamin C enhances oxidation- reduction and regenerative processes, has a desensitizing property and inhibits the secretion and motility of the stomach in patients with peptic ulcer disease. Liquid cereals from buckwheat, oatmeal, barley groats, as well as mucous soups from wheat bran contain a large amount of vitamin W, which favorably affects the nervous system and lowers the acidity of gastric juice. A significant amount of carotene (provitamin L) contains carrots; a rich source of vitamin L is milk and dairy products. All antiulcer diets must include milk.
Qualitatively different diets can influence not only metabolic processes, but also, if possible, normalize the nervous and humoral regulation of the body, stimulate recovery and compensation processes, and reduce inflammatory and allergic reactions.
Under the influence of a diet rich in carbohydrates, the excitability of the autonomic nervous system increases, and the clinical symptoms of an “irritated stomach” increase. The carbohydrate-restricted diet has the opposite effect.
In order for the recovery processes to proceed actively, the nutrition of patients with peptic ulcer disease must be complete and varied with an increased amount of animal protein against the physiological norm.

The course of therapeutic nutrition of patients with peptic ulcer begins with the most sparing diet No. 1a. As a rule, in patients taking this diet, pain and dyspeptic symptoms (heartburn, belching, nausea, vomiting) disappear or decrease. Since this diet is low-calorie (2000-2200 kcal), it is prescribed for no more than 10-12 days. 

Diet number 1a (as sparing as possible)

General characteristics. A diet with a physiological ratio of basic nutrients, a sharp restriction of chemical and mechanical irritants of the mucous membrane and receptor apparatus, with some reduction in calorie content, containing qualitatively different fat.
Culinary processing. All products are boiled, wiped or steamed. Dishes of a liquid or liquid-mushy consistency. Calorie content and composition. Proteins 80 g, fats 80-90 g (of which 15-20 g vegetable), carbohydrates 200 g. Calories 2000-2200 kcal. The amount of free liquid is 1.5 l, sodium chloride is 8 g. The mass of the daily diet is 2-2.5 kg. The fractional diet (5-6 times a day). Food temperature: hot dishes – from 57 to 65 ° C, cold – not lower than 15 ° C. An approximate diet menu No. 1a is given in table. A list of recommended foods and dishes. Soups Mucous from cereals (oat, semolina, rice) with the addition of egg-milk mixture , cream, butter. Bread and bakery products are excluded. Meat and fish dishes. Steam souffle (1 time per day) from lean meats, poultry, fish without tendons, fascia and skin. Dishes and side dishes from vegetables are excluded. Dishes and side dishes from cereals. Liquid mashed cereals (from any cereal, except millet) 1 time per day with the addition of milk or cream.

The most common complication of peptic ulcer is bleeding. Clinical nutrition is prescribed to the patient after stopping or reducing bleeding. Food should be liquid, cold: mucous soups, milk, jelly, jelly, rosehip broth (no more than 200 ml per day) are allowed. With a favorable course of the disease, the amount of food is gradually increased, meat soufflé and soft-boiled eggs are added.

Therapeutic nutrition for peptic ulcer with concomitant diseases

The presence of inflammation from the gallbladder, biliary tract and liver requires a change in diet.
In case of peptic ulcer with concomitant liver and biliary tract disease, a sufficient amount of complete, easily digestible protein and a greater amount of vegetable fats are introduced into the diet. The amount of animal fat is reduced to 50 g, proteins are increased to 120-130 g. Products containing cholesterol are limited . The diet includes carbohydrates, which contribute to the deposition of glycogen in the liver. Exclude dishes that enhance secretion. The food is cooked steamed, in boiled and mashed form. The amount of free fluid is 1.5 liters. The weight of the daily diet is 2.5-3 kg. Fractional diet (6 times a day).
The chemical composition and caloric content of lipotropic diets. Diet number 1a (as sparing as possible). Proteins 90-100 g, fat 70 g (of which 50% vegetable), carbohydrates 250 g. Calorie content 2000 kcal. Table salt 8 g. An approximate menu of the lipotropic diet No. 1a is given in table. Diet number 16 (more stressful). Proteins 100-110 g, fats 75-80 g (of which 50% are vegetable), carbohydrates 350-400 g. Calories 2500-2800 kcal. Table salt 10 g. An approximate menu of lipotropic diet No. 16 is given in table. Diet number 1 (mashed). Proteins 120-130 g, fat 85-90 g (of which 50% vegetable), carbohydrates 450-500 g. Caloric value 3200-3500 kcal. Salt 12 g

Gastric Cancer Epidemiology

Over the past 50 years, the incidence of gastric cancer in developed countries has shown a steady decline. So, in the United States, stomach cancer ranks 13th among the causes of death from malignant tumors: in 2003, 12,100 deaths from cancer of this localization were recorded. At the same time, in developing countries, stomach cancer continues to occupy the 2nd place among the causes of death from cancer, second only to lung cancer. In Russia, the incidence rates are among the highest in the world, characterized by significant regional variability. Most often, stomach cancer develops in Eastern Siberia, in the north of the European part of Russia and in the Far East, more than 2 times less often this disease is found in the south of the country, especially in the North Caucasus region.
According to literature data, men get stomach cancer 1.7 times more often than women, the average age of patients is 65 years (from 40 to 70 years). The decrease in the incidence of gastric cancer occurs due to distal localization due to infection with Helicobacter pylori . In recent years, the frequency of proximal gastric cancers has increased, which may be due to increased incidence rates of Barrett’s esophagus .

The development of gastric cancer can be due to many reasons, its multifactorial etiology is more likely . It can be assumed that the development of a malignant tumor of the stomach includes histological changes starting from atrophy of the gastric mucosa with the subsequent development of metaplasia, dysplasia and malignant changes.
Genetic factors play a significant role in the occurrence of stomach cancer. Examples of the genetic inheritance of the disease have been observed for centuries, the Bonaparte family is the most significant in this regard: Napoleon, his father Charles, grandfather Joseph, and several descendants of Napoleon died of stomach cancer. Patients with hereditary non-polypous colorectal cancer (Lynch II syndrome), an autosomal dominant disease with a high degree of penetrance, have an extremely high risk of developing stomach cancer. In addition, the risk of developing the disease in immediate families of patients with gastric cancer is 2-3 times higher. The high frequency of gastric cancer, mainly of the diffuse type, in patients with blood group A (P) also speaks in favor of genetic factors. Prospective clinical studies have shown that infection with H. pylori leads to a 3-6-fold increase in the incidence of gastric cancer, mainly of the intestinal type, located in the distal third of the stomach. However, it was not possible to prove the role of peptic ulcer due to H. pylori in the onset of cancer, therefore, the colonization of H. pylori plays an independent role in the development of these two forms of pathology. The prevalence of atrophic gastritis and intestinal metaplasia among populations of people in regions with a higher incidence of gastric cancer has been proven. B12-deficient anemia leads to a three-fold increase in the risk of developing cancer, which is probably due to a prolonged decrease in gastric acidity, hypergastrinemia and neuroendocrine hyperplasia. The inverse relationship between the incidence of gastric cancer and socioeconomic status is obvious. It is likely that overpopulation, poor sanitary conditions, and inadequate canning are important. Tobacco smoking , some dietary risk factors (excessive consumption of salty, smoked foods, lack of diet of vegetables and fruits), excessive consumption of alcoholic beverages, poor food storage conditions can lead to stomach cancer. Studies in Japan showed that a decrease in the incidence of gastric cancer occurred in parallel with a decrease in the consumption of salted and dried foods and an increase in the consumption of fresh vegetables and fruits. Foods that are high in nitrite and nitrate, which were previously used to store meat, fish, and vegetables, induce the development of a stomach tumor in animals. Anaerobic bacteria colonizing the atrophied gastric mucosa contribute to the conversion of nitrites and nitrates into TV nitroso compounds , which have a carcinogenic effect. The use of food cooling and the improvement of their preservation methods helped to reduce the incidence of gastric cancer. An increase in vitamin C in food can play a protective role. Controversial is the etiological role in the development of gastric cancer of factors such as benign gastric ulcers, glandular polyps of the bottom of the stomach, hyperplastic polyps. Distal gastrectomy is associated with a high risk (2-3 times) of the development of gastric cancer. In this case, the disease occurs 20-30 years after surgery – the period necessary for the development of intestinal metaplasia, dysplasia and cancer under the influence of prolonged achlorhydria and enterogastric reflux after resection of the stomach. It should be noted the differences in the etiology of distal and proximal gastric cancer and the need for further epidemiological studies to determine the causes of these various diseases.

Stomach cancer begins to develop in a small area of ​​the mucous membrane, then the thickness of the organ wall grows. In addition, the tumor grows along its wall, but mainly towards the cardia , which is due to the peculiarities of lymphatic drainage . The macro- and microscopic boundaries of the tumor almost never coincide. With an exophytic growing tumor, malignant cells are determined at a distance of 2-3 cm from the macroscopically determined border of the tumor, with infiltrative and mixed – 5-6 cm or more. The main histological form of gastric cancer is adenocarcinoma , which accounts for about 90-95% of all malignant tumors of the stomach. The second most common malignant lesion of the stomach is lymphoma . Somewhat less common are leiomyosarcoma (2%), carcinoid (1%), adenoacanthoma (1%) and squamous cell carcinoma (1%). Gastric adenocarcinomas are classified according to microscopic criteria reflecting the degree of tumor malignancy. In order of increasing degree of malignant potential, variants of adenocarcinoma can be arranged as follows: tubular, papillary, mucinous and cricoid-cell adenocarcinoma . According to the alternative histological classification of gastric cancer proposed by Lauren in 1953, they distinguish: 1. Intestinal (epidemic) type of gastric cancer, characterized by expansive growth and preservation of the glandular structure, less invasive growth and the presence of clear tumor outlines, often associated with atrophic gastritis . The intestinal Lauren gastric cancer type corresponds to Borrmann type 1 or II gastric cancer ; its development is associated with the influence of environmental factors, it has a more favorable prognosis, heredity does not affect the occurrence of this type of tumor. 2. Diffuse, or infiltrative, type (endemic), consisting of clusters of low-differentiated cells and characterized by the absence of clear contours of the tumor. The diffuse type of stomach cancer is less associated with environmental factors or diet and is more common at a young age. The emergence of a diffuse type of stomach cancer correlates with genetic factors, blood type, and heredity. To describe the macroscopic parameters of a tumor, researchers use various classification schemes for gastric cancer. In accordance with the most successful, in our opinion, classification proposed by Borrmann in 1926, all tumors of the stomach can be divided into 5 categories: type I – polypoid, or mushroom-shaped, characterized by exophytic growth in the direction of the lumen of the stomach; type II – saucer-type, characterized by exophytic growth with ulceration in the center of the tumor; type III – ulcerative-infiltrative type, characterized by ulceration of an invasively growing tumor; type IV – diffuse-infiltrative type ( linitis plastica ), characterized by diffuse damage to the walls of the stomach, with minimal damage to the mucous membrane and diffuse damage to the remaining layers of the wall of the stomach. The tumor for a long time is asymptomatic , which leads to the fact that the vast majority of patients enter the clinic in a neglected state; type V – unclassified cancer, characterized by a combination of signs of other types of tumors listed above. The increased interest in identifying early cancer in endoscopic research has led to the development of a classification based on an endoscopic macroscopic picture of the disease. The term “early cancer” is used in relation to cancer of the stomach, limited to the mucous and submucous membranes, regardless of the state of the regional lymph nodes. Early stomach cancer is divided into three groups: type I – protrusive ; type II – surface; Type III – saucer-shaped. Type II is divided into three subgroups: 1) elevated; 2) flat; 3) lowered. In Japan, over the past 20 years, the rate of detection of early stomach cancer has increased from 5 to 40%. In Western countries, early stomach cancer is detected in about 9% of cases. The location of the tumor has its own laws and prognostic significance. Cancer of the proximal stomach, sometimes with spread to the lower third of the esophagus, occurs in about 15% of cases. As noted earlier, the incidence of proximal cancer has a tendency to increase, which is especially evident in developed countries. Cancer of the body of the stomach is observed in approximately 30-35% of cases. The most common cancer of the distal stomach is 45-50% of cases. Gastric cancer is characterized by lymphogenous , hematogenous, implantation, and mixed metastasis pathways. Lesion pei of ionic lymph nodes is an example of lymphogenous metastasis and is observed in most patients. The frequency of lesions of regional lymph nodes depends on the depth of invasion by the tumor of the stomach wall. The manifestation of distant lymphogenous metastasis is metastasis to the supraclavicular lymph node, located between the legs of the left sternocleidomastoid muscle (Virchow’s node), and metastases to the ovaries ( Kruckenberg metastases ), which indicate damage to the paraortic lymphatic collector. Examples of the implantation spread of gastric cancer are peritoneal carcinomatosis , malignant ascites, peritoneal lesions of the rectum-uterine cavity ( Schnitzler metastasis ) and navel (metastasis of sister Mary Joseph). The histopathological stage of the tumor remains the most significant prognostic factor for gastric cancer. Numerous clinical trials have confirmed the decisive role of the depth of invasion by a tumor of the stomach wall and the absence or presence of metastatic lesions of regional lymph nodes or distant organs in the duration of disease-free and overall survival of patients with gastric cancer. The main goal of the international classification is the development of a uniform presentation of clinical data and the possibility of comparing treatment results. Pathological staging of gastric malignancies is performed according to the TNM system, based on three components: T – the spread of the primary tumor; N – the presence or absence of metastases in regional lymph nodes; M – the presence or absence of distant metastases. In 1997, the American Joint Committee for the Study of Cancer (AJCC) developed a classification based on the above criteria: Criterion T (primary tumor): Tx – primary tumor cannot be assessed TO – primary tumor is not determined Tis – cancer in situ , intraepithelial cancer without invasion propria mucosa ( lamina propria ) TI – tumor infiltrates own shell mucosa or submucosa T2 – tumor infiltrating the tunica muscularis or subserous layer * TK – tumor invades serosa of the stomach, but without invasion in adjacent organs T4 Tumor invades adjacent structures ** Note. * The tumor can grow the muscle layer, involving the gastrointestinal and gastrohepatic ligaments, or the greater or lesser omentum without perforation of the visceral peritoneum covering these structures. In this case, the tumor is classified as T2. If there is perforation of the visceral peritoneum covering the ligaments of the stomach or omentum, then the tumor is classified as TK. ** Neighboring structures of the stomach are the spleen, transverse colon, diaphragm, liver, pancreas, abdominal wall, adrenal glands, kidneys, small intestine, retroperitoneal space. Intrapartum spread to the duodenum or esophagus is classified by the greatest depth of invasion at all locations, including the stomach. Criterion N (state of regional lymph nodes) The perigastric lymph nodes located along the lesser and greater curvatures, as well as along the left gastric, common hepatic, hepatoduodenal , splenic and celiac arteries , are regional for gastric cancer . Paracardial lymph nodes, as well as lymph nodes along the left gastric, celiac arteries, diaphragmatic, lower mediastinal and peresophageal lymph nodes, are regional for cancer of the cardioesophageal transition . Lesions of other intraperitoneal lymph nodes are regarded as distant metastases. Nx – insufficient data to assess regional lymph nodes N0 – no signs of metastatic lesions of regional lymph nodes N1 – metastases in 1-6 regional lymph nodes N2 – metastases in 7-15 regional lymph nodes N3 – metastases in more than 15 regional lymph nodes nodes criterion M (distant metastasis) Mx – insufficient data to determine distant metastases MO – there are no signs of distant metastases M1 – distant metastases Waters it perfect in terms of the integrals ii morphological studies performed at all stages of treatment of the patient and determining the stage of the disease, a classification proposed by the Japanese Association for the Study of gastric cancer (JCGC) in 1998 g. staging does not change after the first determination and is divided into the following types: 1) clinical – s; 2) surgical – s; 3) morphological – p; 4) final – f. In addition to the characteristics of the primary tumor depending on the depth of invasion (criterion T), gastric cancer is also described depending on the location. The stomach is divided into sodium parts: the upper (U), middle (M) and lower (L) third of the stomach. If the tumor involves more than 1/3 of the stomach, then the third is indicated first, in which the bulk of the tumor is located. In accordance with the cross section of the stomach, the tumor of the stomach can be located on the front ( ant ) or back ( post ) wall, small ( less ) or large ( gre ) curvature. According to the classification proposed by JCGC, the gradation of regional lymph nodes is built depending on the localization of the pathological focus. Such a system of lymph node groups based on research to explore ways of lymph in gastric cancer of different locations, as well as data survives – gi according to defeat each group of lymph nodes. According to the JCGC classification, metastatic damage to the lymph nodes takes place in three stages. At the first stage, perigastric lymph nodes located in the ligaments of the stomach are affected . These include: 1) right paracardial lymph nodes; 2) left paracardial lymph nodes; 3) lymph nodes of the lesser curvature of the stomach; 4) lymph nodes of the greater curvature of the stomach; 5) suprapiloric lymph nodes; 6) subpiloric lymph nodes. The lymph nodes of the second stage of metastasis include lymph nodes located along the celiac trunk and its branches, the common hepatic, left gastric, splenic arteries, as well as in the gates of the spleen. The second stage groups include: 1) lymph nodes along the left gastric artery; 2) lymph nodes along the common hepatic artery; 3) lymph nodes around the celiac trunk; 4) lymph nodes in the gate of the spleen; 5) lymph nodes along the splenic artery; 6) lymph nodes of the hepatoduodenal ligament. Different groups of lymph nodes, even groups belonging to the first stage of lymphogenous metastasis, can be considered as the next stage of metastasis or as a manifestation of distant metastasis depending on the location of the tumor in the stomach. Thus, metastatic lesion of the left paracardial lymph nodes (group No. 2) in cancer of the lower third of the stomach is regarded as distant metastasis.

Early gastric cancer can manifest with symptoms of dyspepsia of varying severity. In cancer with invasion only of the mucous membrane, complaints of dyspeptic disorders are presented by more than 50% of patients, therefore, in the presence of dyspepsia and over the age of 40 years, an endoscopic examination is recommended . In the presence of dysplastic changes in the gastric mucosa, regular endoscopic examination is necessary. The duration of symptoms before surgery for early gastric cancer ranges from 3 to 72 months. With early gastric cancer, there are no physical signs of the disease, although some patients (about 10%) have a slight pain on palpation in the upper abdominal cavity.
In the early stages of gastric cancer, the course of the disease may be asymptomatic. When non-specific complaints appear, patients often attribute them to the manifestations of functional disorders of the upper gastrointestinal tract and do not seek medical help for a long time. However, with a thorough history, even in the early stages of the development of the disease, complaints related to stomach cancer can be identified. So, a feeling of “abdominal fullness” or a slight pain at the end of a meal may indicate cancer of the antrum . Cancer symptoms may resemble those with peptic ulcer, especially when the tumor is localized by lesser curvature. A tumor of the cardiac section of the stomach in 60% of patients can manifest with dysphagia, which indicates obstruction of more than 80% of the lumen of the abdominal esophagus or cardia . With this localization of gastric cancer, there is a need for differentiation with achalasia or cancer of the esophagus. Pathognomonic symptoms of gastric cancer occur with large sizes of the primary tumor, which leads to obstruction of the lumen of the stomach, with functional disorders resulting from the involvement of a large part of the wall of the stomach in the tumor process, if bleeding occurs. More than 70% of patients report complaints for more than 6 months. before going to the doctor. The most characteristic complaints are a feeling of heaviness and pain in the epigastrium , aggravated after eating, weight loss, nausea, vomiting of recently eaten food, hematomesis , melena, anorexia, rapid satiety with food, bloating. Pain in gastric cancer can simulate tenocardia or benign pathology of the stomach, weakening after eating.
In about 10% of patients, on initial treatment, palpable lymph nodes on the neck, ascites, jaundice are detected, and formation in the abdominal cavity is palpated. However, the presence of a palpable tumor in the abdominal cavity does not always indicate unresectable gastric cancer. Metastasis of sister Mary Joseph in the form of a palpable node in the navel is a fairly frequent manifestation of advanced cancer of the stomach, is an unfavorable prognosis factor. When this symptom appears, the median survival is not more than 3.5 months. Less commonly observed are superficial thrombophlebitis of the lower extremities ( Trusso’s symptom ).
The clinical picture of gastric cancer is determined by the localization of the tumor process in the stomach.
Cancer of the proximal stomach can be manifested by dysphagia, which leads to protein starvation, hypovolemia . In the future, general symptoms in the form of weakness, fatigue, weight loss, dizziness, etc. join. Dysphagia is often accompanied by profuse salivation. Cancer of the fundus of the stomach before the onset of clinical symptoms can reach significant sizes, the appearance of a pain syndrome indicates the spread of the tumor to neighboring structures. Cancer of the middle third of the stomach for a long time does not manifest itself clinically. Patients often make general complaints. With ulceration of the tumor, subfebrile temperature can be observed, and with tumors of lesser curvature, one of the first clinical signs of the disease is gastric bleeding. The appearance or intensification of pain in cancer localized in the middle third of the stomach may indicate the spread of the tumor to the pancreas. Cancer of the lower third of the stomach in the early stages of development can manifest as dyspepsia, halitosis. As the tumor grows and stenosis of the lumen of the output section of the stomach is attached, first burp air, then vomit the food eaten the day before. In connection with the violation of the passage of food through the gastrointestinal tract, general symptoms gradually increase.

Laboratory research

There are no laboratory tests specific to early gastric cancer. However, laboratory data may undergo changes in advanced gastric cancer. The most common finding is iron deficiency microcytic hypochromic anemia. Even with early cancer, 20% of patients have a decrease in hemoglobin levels. Platelet counts and blood coagulation rates remain within normal limits, with the exception of cases of massive bleeding, disseminated intravascular coagulation, metastatic lesions of the liver, lungs, pancreas, spleen and bone marrow.
Among the biochemical parameters, a slight increase in the level of activity of lactate dehydrogenase and alkaline phosphatase and a decrease in the level of albumin, some fractions of proteins, iron and ferritin in the blood serum can be noted .
A test for occult blood in feces can be negative in about half of patients with advanced gastric cancer. At the same time, a positive benzidine test can be characteristic of patients with pathology in any part of the gastrointestinal tract: peptic ulcers, erosion, gingivitis, reflux esophagitis, hemorrhagic gastritis, hemobilia , colitis, colon polyps, colorectal cancer, hemorrhoidal nodes. An analysis of feces for occult blood can give a false positive result, especially if the patient on the eve ate steaks with blood, turnips, broccoli and radishes. In people older than 40 years, a positive result is an indication for the study of the colon ( colonoscopy or sigmoidoscopy + irrigoscopy with double contrast). The level of tumor markers does not increase with early gastric cancer. The most common gastric cancer cases are CA19-9, CA50, CA72-4, CA546, and CEA. Highly and moderately differentiated tumors are characterized by an increase in the level of at least 2-3 markers, while in patients with low- and undifferentiated tumors of the stomach, the level of markers does not increase. Multivariate analysis suggests that tumor markers are independent prognostic factors and are second only to T, N, and M.

Endoscopic examination

It is aimed at solving the following two problems: screening to identify patients with non-tumor pathological changes in the mucous membrane and the formation of risk groups; detection of stomach cancer. During endoscopic examination, boundaries, the nature of growth, the shape of the tumor, the absence or presence of spread to the esophagus are fixed. In solving the second problem, the detection of early cancer is of great importance. In some cases, there is a need for chromoendoscopic examination. For this, the gastric mucosa is stained with a 0.1% solution of indigo carmine, which makes it possible to visualize the boundaries of infiltration even with endophytic growth of cancer and synchronous tumors or metastases along the gastric mucosa. For morphological diagnosis, a tumor biopsy is performed to obtain material for histological and cytological studies.

Endoscopic Ultrasound

Endoscopic ultrasound of the stomach in many specialized medical centers around the world is included in the register of standard examination methods. Direct contact of the ultrasound probe with the wall of the stomach allows you to get a high degree of resolution when visualizing the layers of the organ wall. This makes endosonography an ideal method for assessing the depth of invasion according to the TNM classification. The criteria for metastatic damage to the lymph nodes are the size of the node more than 5 mm in diameter, rounded shape (a spherical shape is more characteristic for inflammatory nodes) and well-defined contours. Thus, endosonography is an effective and generally accepted method for staging cancer of the stomach. When assessing the depth of invasion (T) and the state of regional lymph nodes (N), the accuracy, sensitivity and specificity of the method, according to different authors, ranges from 80 to 95%.

Endosonography

One of the priority tasks of endosonography in recent years has been the evaluation of the effect of neoadjuvant therapy, since combined treatment is playing an increasingly important role in the treatment of gastric cancer. A study performed prior to the start of treatment does not have predictive significance in relation to the possible effect of chemo – or chemoradiotherapy. The restoration of the structural structure of the stomach wall, established on the basis of endoscopic ultrasound, is obviously a sign of the full effect in the patient after neoadjuvant treatment, however, in some cases, endosonography data is difficult to interpret due to the development of inflammatory and fibrotic changes in the primary tumor or in its place .

X-ray examination

An X-ray study using suspensions of barium sulfate as a contrast has two main tasks: screening for gastric cancer and determining the prevalence (depth of invasion and extent) of the malignant process. Most successfully, the first problem was solved in Japan. At the same time, the priority is not the detection of stomach cancer, but the formation of risk groups for subsequent observation. The solution to the second problem is especially relevant before surgery.
The main methods of contrast x-ray examination are tight filling and double contrasting.
In early gastric cancer with an exophytic nature of growth during an X-ray examination, a filling defect is detected. The size of the filling defects varies from 1 to 4 cm in diameter. However, the nature of the surface of a polypoid formation is of greatest importance in the interpretation of data from a contrast study. The contours of a benign hyperplastic polyp are clear, even, while for a malignant tumor, the uneven, serrated contours of the tumor are more characteristic. However, despite the roughness of the contours of early cancer, the surface topography of the polypoid early cancer is similar to that of the surrounding gastric mucosa. Thus, in gastric cancer with invasion of the stomach wall no deeper than the submucosal layer, the tumor surface has the same contours as the surrounding mucous membrane. This symptom is most important in the differentiation of early and widespread gastric cancer. As the tumor grows and the deeper layers of the stomach wall are involved in the tumor process, the similarity between the relief of the mucous membrane and the surface of the tumor is lost, erosion, ulceration ( Borrmann type II ) appear , which is observed in about 26-27% of cases of stomach cancer. Sometimes, despite the increase in the size of the tumor, its ulceration does not occur, this type of tumor is observed in 2-3% of cases (type I according to Borrmann ). Peristalsis at the lesion level is not visible, folds of the mucous membrane break off at the edge of the filling defect.
With early endophytic cancer of the stomach, the x-ray picture is determined by two dimensions, with advanced cancer – three. In other words, with early cancer, the depth of invasion may be omitted, while this parameter is crucial in the more common stages of the disease. The contours of early cancer with an infiltrative nature of growth are clearly traced, but in some cases, when the border between the normal mucous membrane of the stomach and early cancer is blurred, the detection of early cancer presents significant difficulties. Common gastric cancer with an infiltrative nature of growth is most often radiologically represented by a defect in filling or a barium depot, elevated tumor edges and the absence of peristalsis in the affected part of the stomach. In cases of insignificant involvement of their own muscle membrane, widespread gastric cancer radiologically resembles early cancer. This form of common cancer is of type V according to Borrmann . Borrmann type III occurs in 40-45% of cases and is characterized by the presence of a filling defect, a crater with uneven contours in the center of the tumor and the absence of peristalsis around the pathological focus, which is due to the infiltrative growth of cancer. (mucosal clutches break off at the edge of the tumor. Borrmann type IV is found in 21% of cases of widespread gastric cancer. In Western literature, this type is called diffuse infiltrative carcinoma. The x-ray picture of the thickening of the wall of the stomach in a significant area is due to tumor tissue infiltration and the development of fibrotic changes. radiographically stomach deformed , poorly extensible most often affected first antral department. Iposledstvii erosion and ulceration takes considerably the surface of the tumor lesion. Linitis plastica is a kind of type IV advanced cancer Borrmann , is observed most often in the age of 40 years. radiologically characterized by deformation and a decrease in size of the stomach, thickened folds. Identification linitis plasllea in the early stages of tumor development is significant fudnosti and is the only unsolved a problem in diagnosing early stomach cancer.

CT scan

Computed tomography of the chest and abdominal cavity is also included in the list of studies necessary to evaluate a locally advanced tumor process. CT allows you to establish the size of the primary tumor, enlarged lymph nodes of the retroperitoneal space, metastases in the lung tissue and liver, the presence of lymph nodes affected by metastases along the celiac trunk and its branches. An important condition for proper treatment planning is an accurate assessment of the prevalence of the Process. Despite the fact that CT is part of the algorithm for examining a patient with esophageal cancer, the method is ineffective in determining the depth of invasion of the stomach wall by a tumor.

Ultrasound computed tomography

Ultrasound computed tomography of the organs of the abdominal cavity, retroperitoneal space and cervical-supraclavicular zones allows to detect metastatic lesions of the lymph nodes in the corresponding anatomical areas, as well as distant metastases in the liver and kidneys. P

Ozitron Emission Tomography (PET)

Malignant tumors are characterized by increased glucose metabolism. PET using radioactive labeled fgor-18-deoxyglucose (FDG) allows visualization and quantification of glucose metabolism in tumor tissue. FDH is phosphorylated with the participation of the hexokinase enzyme , converted to FDH-6-phosphate and accumulates in the tissues. By the time of execution of I D) T (60 min after injection), the activity of glucose metabolism in tissues is represented by the concentration of FDH-6-phosphate in the tumor. The use of PET is effective for identifying the primary lesion, affected lymph nodes and distant metastases in cancer of the lung, breast, lymphoma , squamous cell carcinoma of the head and neck, malignant tumors of the musculoskeletal system and colorectal cancer. And only recently have data appeared on the effectiveness of the method in the diagnosis of gastric cancer.

With adequate treatment for early gastric cancer, survival can exceed 90%. The frequency of lesions of regional lymph nodes in TI with invasion within the mucous membrane is about 4%, with invasion of the submucosal layer – 23% and correlates with factors such as the form of growth, the presence of ulceration, the size, and the degree of differentiation of the tumor. Therefore, with a highly differentiated tumor less than 3 cm in size, in the largest dimension and without signs of ulceration, its endoscopic resection is possible.

Surgery

The surgical method remains the main one in the treatment of stomach cancer. According to the recommendations of ESMO (2005), surgical treatment is recommended for the following tumor prevalence according to the TNM system: Tis-T3N0-N2M0 and T4N0M0. With gastric cancer, a gastrectomy or resection of the stomach of various sizes is performed with the removal of the ligamentous apparatus and regional lymph nodes. Subtotal proximal resection of the stomach is performed with exophytic cancer of the proximal stomach, which does not extend beyond the cardia . An indication for subtotal distal gastric resection is an exophytic tumor of the distal stomach, which does not extend proximal to the angle of the stomach. With infiltrative tumors of various localization, total lesion, exophytic tumor of the body of the stomach, gastrectomy is indicated . In order to achieve the radicality of surgical intervention with type I and II according to Borrmann, it is necessary to retreat more than 3 cm from the proximal edge of the tumor, with type III and IV – 6 cm. The published data do not allow to confirm the advantage of one volume of surgical intervention over another. The volume of lymph node dissection has been the subject of controversy to this day. Lymphatic dissection D2 is the standard volume for gastric cancer surgery as recommended by the JCGC. Clinical trials conducted in Japan showed improved survival in the absence of an increase in the incidence of complications and mortality in patients undergoing gastrectomy with D2 lymphadenectomy . However, studies by MRC and the Dutch group for the study of gastric cancer, which involved 400 and 711 patients, respectively, did not reveal an increase in survival after lymph node dissection D2. In both studies, in the group of patients with extended lymphadenectomy , an increase in the frequency of postoperative complications and mortality was noted, which was most likely associated with the performance of distal pancreatic resection of the pancreas and splenectomy in these patients , procedures that are not necessary to remove the lymph nodes. In addition, the volume of lymphatic dissection did not always correspond to the volume L) l or D2, which further complicated the interpretation of the results and comparison of groups.

Chemotherapy

Chemotherapy in an independent treatment option is used in patients with disseminated gastric cancer. The main chemotherapy drugs for this disease are fluorouracil , cisplagine , mitomycin and taxanes . According to the literature, the frequency of objective effects during chemotherapy with these drugs ranges from 17 to 30%. The use of chemotherapy, according to randomized trials, can extend the life of patients with distant metastases up to 12 months.
When using combination chemotherapy, the effectiveness of treatment is higher. The most commonly used regimens are PF ( cisplatin and fluorouracil ), ELF ( fluorouracil , calcium folinate and leucovorin ), FAMTX ( fluorouracil , doxorubicin , calcium folinate and methotrexate ), PEF ( cisplatin , etoposide and fluorouracil ).
Recently, the use of taxanes , irinotecan , capecitabine has been recognized . The use of docetaxel and cisplatin was effective in 37% of patients with gastric cancer.

Neoadjuvant chemotherapy

The need for chemotherapy at the first stage of the combined treatment of gastric cancer is confirmed by studies on autopsy material, which showed that even in the early stages, cancer of this localization often becomes systemic. Modern studies on the efficacy of laparoscopy and PET in assessing the prevalence of tumors confirm this thesis. Neoadjuvant treatment leads to a decrease in the bulk of the tumor in most patients, increased resectability , and reduces the risk of intraoperative seeding of the wound with tumor cells. In addition, a histological examination of the removed preparation makes it possible to objectively evaluate the effect of treatment performed before surgery. There are several theoretical and experimental justifications for the use of chemotherapy precisely at the preoperative stage of treatment of patients with gastric cancer. Experimental studies show that surgical intervention stimulates the growth of tumor cells remaining in the patient’s body after surgery. This is evidenced by an increase in the proliferation index, a significant decrease in cell replication time, and a rapid increase in the number and size of distant metastatic foci after surgery. An increase in the proliferation index may be accompanied by mutations leading to the formation of cell clones resistant to chemotherapy. An additional argument in favor of the use of neoadjuvant treatment (chemotherapy) at the preoperative stage is the best delivery of chemotherapeutic agents to the tumor tissue in conditions of blood flow in the tumor bed not compromised by surgical intervention.
To date, the literature has published the results of three clinical studies on the effect of neoadjuvant chemotherapy on treatment efficacy. As a result of chemotherapy before surgery, it was possible to reduce the prevalence of the tumor process, however, one of them failed to improve the survival of patients in the group with preoperative chemotherapy.

Adjuvant chemotherapy

Metastatic damage to the lymph nodes is a prognostically unfavorable factor in patients who received radical surgical treatment, which gives rise to attempts to improve survival in high-risk patients through the use of adjuvant chemotherapy. A large number of clinical trials on the use of chemotherapy in the postoperative period have been published in the literature. The studies completed to date on the role of adjuvant chemotherapy after surgical treatment do not allow us to draw final conclusions about its effectiveness. Only a few of them managed to improve the treatment results in the group with combined treatment compared with patients who underwent only surgical treatment. At the same time, a meta-analysis of all clinical studies shows a slight, but obvious improvement in survival in the main group of patients. To confirm these data, carefully planned clinical trials using new effective drugs are necessary. The most commonly used drugs are mitomycin , fluorouracil , anthracyclines . More often a combination of two or more drugs is used.

Adjuvant Intraperitoneal Chemotherapy

The use of this adjuvant treatment regimen is due to the rather high rate of relapse in the abdominal cavity. Clinical studies have been conducted on the use of cisplatin , mitomycin and fluorouracil for intraperitoneal adjuvant chemotherapy. However, there was no significant improvement in long-term results.

Radiation therapy

As an independent method, radiation therapy is carried out in case of locoregional relapse of gastric cancer after surgical treatment or as an additional treatment in the presence of tumor cells along the line of resection of the surgical preparation. The use of radiation therapy in adjuvant mode to date remains an experimental direction in the treatment of gastric cancer. The widespread use of radiation therapy in combination with chemotherapy in adjuvant and neoadjuvant modes. Despite preliminary favorable results, it cannot be recommended for widespread use in preoperative or postoperative treatment.

Stomach cancer prognosis

According to statistics, the most favorable prognosis is characteristic for cancer of the antrum and pyloric canal of the stomach – 5-year survival exceeds 35%. The least favorable cancer is proximal gastric cancer – survival rate of less than 20%. An intermediate position is occupied by cancer of the body of the stomach, 5-year survival with this localization ranges from 25 to 35%.

Acute gastritis, gastroenteritis are gastrointestinal disorders caused by nutritional errors (overeating, eating unusually spicy and too rough food, unripe fruits, etc.), using stale, infected foods to eat. In addition, severe disorders from the stomach and intestines can occur a second time with various, and especially infectious, diseases.
Acute gastritis and gastroenteritis are quite common, especially in preschool children. However, a significant number of patients, due to the comparative ease and short duration of the course of the disease, are cured with home remedies and remain outside the field of vision of the doctor. In many cases, the diagnosis of acute gastritis and gastroenteritis is not recorded, considering gastrointestinal disorders as a manifestation of general intoxication in various infectious and somatic diseases. Meanwhile, a morphological study of the mucous membrane of the stomach and intestines reveals distinct inflammatory and dystrophic changes in such cases.

Depending on the etiology and related features of the pathogenesis and clinic of the disease, there are alimentary, texico- infectious and secondary ( para-infectious ) forms of acute gastritis (gastroenteritis). The first two forms are more often observed in the summer, which is facilitated by the lability of the digestive processes under conditions of overheating, a greater possibility of overeating unripe fruits and berries, as well as the comparative ease of spoilage and infection of food products. Acute gastritis occurs more easily in children weakened, as well as in children with hypersensitivity to certain food ingredients.

Clinic of acute gastritis, gastroenteritis

Alimentary form of acute gastritis

The alimentary form of acute gastritis begins suddenly in the midst of full health, 4-8 hours after a violation of the diet. Abundant, sometimes repeated vomiting with the remnants of food in the vomit is usually preceded by a period of discomfort when the child complains of malaise, chills, nausea, headache, a feeling of fullness of the stomach and spilled pain in the abdomen. When examined, pale skin and lethargy of the child are noteworthy. . The tongue is coated with a coating, a sweet smell of fermentation from the mouth appears, with repeated vomiting – the smell of acetone. The abdomen is slightly swollen, on palpation it is sensitive in the epigastric region, sometimes the body temperature rises to 38 – 39 ° С. In mild cases, the child’s condition after vomiting quickly improves, and in the next 1 to 2 days, he recovers.
Occasionally, preschool children may develop severe general intoxication, resembling a picture of toxic dyspepsia. Vomiting is repeated even after drinking water, diarrhea intensifies, oliguria occurs . In the urine, protein, gzone , cylinders are determined . Against the background of severe dehydration and impaired salt metabolism, signs of irritation of the meninges, convulsions, symptoms of damage to the cardiovascular system – dull heart sounds, frequent and low heart rate, and a tendency to lower blood pressure can occur.

Toxic infectious form

The toxic-infectious form of the disease usually proceeds as gastroenteritis or gastroenterocolitis , signs of a predominant lesion of the stomach are detected less often. In the first case, food infection, leading to the development of the disease, is caused by microbes from the Salmonella group, sometimes Escherichia coli, in the second – more often by staphylococci. Features of the course of the disease depend on the age and reactivity of the child’s body, the massiveness of the infection, and also the virulence of the flora.
The duration of the incubation period ranges from several hours (staphylococcal infection) to a day or more (salmonellosis). The clinical picture of the disease is very similar to that described in the alimentary form of acute gastritis, however, intoxication and dehydration are more pronounced, more persistent vomiting and diarrhea, the nervous and cardiovascular systems are more often involved in the pathological process, the level and prolonged period of increase in body temperature are higher. In severe cases, the process recovery is delayed up to 7-10 days, and if untimely or improper treatment can be fatal.

Secondary acute gastritis

Secondary acute gastritis, complicating severe infectious and somatic diseases (scarlet fever, measles, viral respiratory diseases, dysentery, rheumatism, glomerulonephritis , etc.), develops due to the high sensitivity of the gastric mucosa to trophic disorders and pathological metabolic products circulating in the blood. Intravital diagnosis of gastritis is difficult, as the nausea, vomiting, abdominal pain and other symptoms that are observed in this case are often interpreted as a manifestation of the underlying disease. Meanwhile, the probability of developing gastritis is evidenced not only by morphological studies. It has long been known that the diet has a beneficial effect in these diseases, not only taking into account metabolic disorders associated with toxicosis, but also sparing the mucous membrane of the stomach and intestines. Strict adherence to such a diet and the subsequent gradual expansion of the diet in combination with stimulating vitamin and enzyme therapy can prevent the development of functional disorders of the alimentary canal, anorexia, and reduced food tolerance in convalescents .