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Gastric Cancer
Jackie Farrall
Orange Regional Medical Center
Orange Regional Medical Center is located in Middletown, New
York, 60 miles north of New York City in the heart of the
Hudson Valley. The facility is an acute care hospital with 353
private rooms, 2400+ employees, caring for diversified
population. They treat a variety of medical and surgical
conditions with units that include, ICU, Pediatrics, NICU,
Bariatric, OB, Behavior Health Unit and Rehabilitation.
• The facility has 7 RD’s, 5 with advanced degrees, two certified
in Nutrition Support. In addition, they have two DTR’s that
are Certified Dietitians/Nutritionists in New York State.
• ORMC serves 1,000 patient meals a day and approximately
800 employee/guest meals a day. The meals are provided to
the patients through the Hostess Program operated through
Gem Serve.
Pathophysiology
Pathophysiology
• Cancer cells grow at an uncontrollable
rate
▫ An enzyme is secreted that destroys the
telomere, leading to the loss of the cell’s
internal clock for counting mechanismpermitting uncontrolled cellular
replication.
• The cancer cell becomes autonomous
from the normal growth signals and
genetic control
• Initiating: for example tobacco
• Promoters require an activation of the
carcinogenic as well as failure to natural
immunity and cellular repair
mechanisms
Pathophysiology
• Stomach cancers can spread (metastasize) in
different ways.
▫ Grow through the wall of the stomach and invade
nearby organs.
▫ Spread to the lymph vessels and nearby lymph nodes.
 The stomach has a very rich network of lymph vessels and
nodes.
• As the stomach cancer becomes more advanced, it
can travel through the bloodstream and spread to
organs such as the liver, lungs, and bones. If cancer
has spread to the lymph nodes or to other organs,
the patient’s outlook is not as good.
Risk Factors
Causes
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• Environmental Factors
▫ Low Socioeconomically
status
▫ Tobacco
• Helicobacter pylori
▫ Chronic Atrophic Gastritis
• Diet
• Previous stomach surgery
• Pernicious Anemia
Gender
Age
Ethnicity
Family History
Type A Blood
Menetrier Disease
Certain occupations
Common Variable Immune
Disease (CVID)
Signs and Symptoms
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Poor appetite
Unintentional weight loss
Abdominal pain
A sense of fullness in the upper abdomen after
eating a small meal
Heartburn or indigestion
Nausea
Vomiting, with or without blood
Swelling or fluid build-up in the abdomen
Anemia
How is Gastric Cancer Diagnosed?
• Medical history and
physical exam
• Upper Endoscopy
▫ Endoscopic Ultrasound
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Biopsy
Imaging Tests
Laparoscopy
Barium Swallow
Lab tests
Treatment
• Surgery
▫ Subtotal gastrectomy
▫ Total gastrectomy
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Chemotherapy
Radiation therapy
Chemoradiation
Targeted therapy
Gastrectomy Treatment
Meet Cyrus
• Ht: 6’2” (1.88 m)
• Wt: 109 lb (49 kg)
• Wt History:
• 122 lb 4/18/15
• 156 lb 11/18/15 Placement of PEJ
• Ideal Body Weight:
• 190 lb (86 kg)
• BMI: 14.78 kg/(m^2)
• BMI classification: Severely Underweight
• Skin integrity: Stage II buttocks and Stage II coccyx
• Medications: Humalog, Magic Mouthwash suspension,
Protonix, Folic Acid, Zofran, Mag-sulfate, Morphine and
receives vitamin B shot once week at Oncologist office
Obtained from medical chart in Epic
Meet Cyrus
• Medical History: Hepatitis C, substance abuse,
Gastric Cancer, COPD Type A blood and weight loss
(30 lb since November 2014)
• Surgery History:
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Colonoscopy, biopsy 6/14
Endoscopic ultrasound 7/14
EGD 7/14
Total gastrectomy 11/14
PEJ tube 11/14
• Family History:
• Mother- Cancer
• Father- Cancer
Obtained from medical chart in Epic
Diet History
• Past Diet History:
• J-tube was removed February and has been losing weight
due to not being able to eat without burning sensation
• Recent Food Intake:
▫ TPN @ 60 cc/hr with pleasure feedings (1,267 calories, 72 gms of
protein)
▫ Ground meats, Ensure Complete TID (1,050 calories, 39 gms of
protein), Gelatein 20 BID (180 calories, 40 gms of protein)
▫ Pleasure feedings:
 Breakfast: eggs, toast, coffee, yogurt
 Lunch: hamburger
 Dinner: mashed potatoes, ground chicken
• Diet Education:
▫ Educated pt on soft and ground meats and GERD diet for
esophageal discomfort
Obtained from medical chart in Epic
Labs from 4/26/15
Sodium
137
Magnesium
1.7
Potassium
3.6
Total Protein
5.7
Chloride
98
Total Bilirubin
0.4
CO2
34
Anion Gap
5
Albumin
2.3
Glucose
98
AST
64
ALT
131
324
Glucose POC 120
BUN
17
Alkaline
Phosphatase
Creatinine
0.2
Bilirubin direct
.12
Calcium
8.3
Vitamin B12
1173
Bilirubin
indirect
.28
Obtained from medical chart in Epic
Diagnosis
• Malnutrition related to gastric Ca as evidence by
BMI of 14.76 kg/(m^2) and 31% UBW loss in the
past 5-6 months.
• Increase protein needs related to wound healing
as evidence by Stage II on coccyx and Stage II on
buttocks.
Medical Nutrition Therapy
• Nutrient Needs: 2,000-2,200 calories (40-45
calories/kg), 100 grams of protein (2 gm/kg), 2000 cc’s
H2O (1 cc/calorie or per MD)
• TPN D20 to 60 cc’s/hr, add lipids, 20% in 250 ml 2 x
week
▫ 60cc (24 hr)= 1440 cc/day
▫ CHO: 1440cc (.2 dextrose)= 288 gms of CHO
 288 gms (3.4 gm/cal)= 979 calories of CHO
▫ Protein: 1440 cc (.05)=72 gms of Protein
 72 gms (4 gms/cal)=288 calories of Protein
▫ Lipids: 20% in 250ml= 500 calories/7 days= 72 calories
▫ Which will provide 1,339 calories, 72 gms of protein,
1440 cc’s H2O
Medical Nutrition Therapy
• Osmolite 1.2 @ a goal of 80 cc/hr
▫ 80 cc/hr (24 hr)= 1,920 cc/day
▫ 80 cc/hr (24 hr)(1.2 cal)= 2,304 calories
▫ Protein: 1920 cc (55.5 gm)/ 1,000= 107 gms of
protein
▫ Fluid: 1920 cc (820 ml of fluids)/ 1,000= 1574 cc of
free water
 1920 cc/day – 1,574 cc of free water= 346 ml of fluids
 346 ml / 3 nursing shifts = 115 ml fluid flush ever 8
hours to meet hydration needs
▫ Which will provide 2,304 calories, 107 gms of
protein, 1574 cc free water, 115 ml fluid flush
ever 8 hours to meet hydration needs
Intervention
• Enteral and parenteral nutrition support
• Osmolite 1.2 increase as tolerated, to a goal of 80
cc/hr
• Taper and D/C TPN ONLY when tube feeding is
tolerating is meeting 60% of pts needs (Osmolite
1.2 @ 60 cc/hr)
Journal of Parenteral and Enteral Nutrition, 2009
Monitor
• Tolerance to pleasure feedings, TPN support and
plans for PEJ placement and nutritional
supplements- Gelatein 20 and Ensure Complete
• Monitor labs, skin integrity and clinical status
• Check pts weight
Evaluation and Responses
• Continue pleasure feedings and
supplements at this time
• Pt received a PEJ tube once his
Albumin reached 2.0.
▫ Recommended to start Osmolite 1.2
@ 30 cc/hr, increase as tolerated, to
a goal of 80 cc/hr
Evaluations and Responses
• Pt did not tolerate Osmolite @ 80 cc/hr
▫ Goal rate of Osmolite 1.2 @ 65 cc/hr, which will
provide 1,560 calories, 86.6 gms of protein,
1279 cc free water
▫ Provide Prostat TID via J tube or consistently by
mouth, which will provide 300 calories, 45 gms
of protein/day.
▫ Total provision= 2,172 calories, 132 gms of
protein, 1279 cc free water and will require
~150 ml fluid flush ever 8 hours (without
IVF)
Evaluation and Responses
• MD requested calorically dense
formula preferred with 12 hour
infusion rate
▫ Recommend TwoCal HN to a goal of
85 cc/hr
 Which will provide~ 2,040 calories, 85
gms of protein, 714 cc of fluid and will
require 300 cc fluid flush every 8 hrs
to meet hydration needs.
▫ Educated pt and wife about GERD
diet
References
About Us. (2015). Retrieved August 10, 2015, from Orange Regional Medical Center
website: http://www.ormc.org/
Escott-Stump, S. (2012). Nutrition and diagnosis-related care (Seventh ed.). Batlimore, MD: Lippincott Williams & Wilkins.
Gastric cancer. (2013). Retrieved from Hopkins Medicine website:
http://www.hopkinsmedicine.org/gastroenterology_hepatology/_pdfs/esophagus_stomach/gastric_cancer.pdf
Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. (2009). Journal of
Parenteral and Enteral Nutrition, 33(3), 290-292.
Mahan, L. K., & Escott-Stump, S. (2004). Food and nutrition diet therapy (11th ed.). Philadelphia, PA: Saunders.
Nelms, M., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition therapy & pathophysiology (2nd ed.). Belmont, CA:
Brooks/Cole Cenage Learning.
Stomach cancer. (2014, May 20). Retrieved August 6, 2015, from American Cancer Society website:
http://www.cancer.org/acs/groups/cid/documents/webcontent/003141-pdf.pdf
TwoCal HN. (2015). Retrieved August 6, 2015, from Abbott Nutrition website:
http://abbottnutrition.com/brands/products/twocal-hn