Peter is 58 years old. A few months ago, he has started to notice a pain in his “stomach”. It began with a poorly defined discomfort, but now it’s a dull, continuous pain that lasts throughout the day, and is not relieved by antacids.
John is 52 years old. After a few months noticing discomfort in the upper abdomen. He has begun to have nausea and vomiting every time he eats a normal amount of food. Because of that, he is losing a lot of weight, and other people are noticing it.
Stomach cancer is one of the malignant tumours that usually takes time for us to notice its symptoms. When a person suffers from it, he usually delays consulting with a doctor.
It is a pain that begins as a nuisance, poorly defined and poorly localized in the abdomen. It’s like the feeling of indigestion, or the abdominal disturbance of people with gastritis. Over time it’s accentuated and tends to be in the central part of the belly, just below the ribs. Unlike the pain of gastric or duodenal ulcer, the pain due to stomach cancer doesn’t usually change significantly neither with food ingestion, nor with taking antacids.
When stomach cancer is in the region of entry of food from the esophagus to the stomach, an area called cardia, the tumour can hinder the entry of food we have eaten, producing two symptoms:
- Symptom 1: We can note that, when swallowing food, these foods get stuck in the chest. When this happens, we will have to swallow water to help the bolus get into the stomach.
- Symptom 2: Bitter waters may start coming to the mouth. This gastroesophageal reflux appears because stomach cancer is very close to the lower esophageal sphincter, which can cause it to incompletely close.
When this happens, food with gastric juices can escape from the stomach upwards, towards the oesophagus, causing the acid reflux.
When stomach cancer is located at the pylorus, which is the region of the stomach that drives food into the small intestine, it may obstruct or even close this natural outlet of the gastric content. If the exit is obstructed, when we have enough food in the stomach it detects that gastric content will not be emptied. Therefore, it informs the brain, so that it triggers the sensation of nausea and starts the vomiting reflexes. We’ll vomit what we have ingested.
The less common variety of stomach cancer is the diffuse variety, which affects the entire stomach, not just one of its parts. If the entire stomach is infiltrated by tumour cells, its wall distensibility decreases. When we start taking food, the stomach with this type of tumour does not distend properly, so it feels full easily.
This filling communicates to the brain the satiety sensation, so the person with this type of gastric cancer stops eating. People with gastric cancer tend to eat fewer calories. This is because they have stomachache or have food stuck as it enters the stomach or due to vomit or even because there’s no space the stomach for food.
Gradually the person with stomach cancer will get thinner and thinner. Because the tumour can break the stomach lining and thus a blood vessel, either from the stomach or from the tumour itself, the person with stomach cancer may start bleeding without knowing it. When bleeding is minor, symptoms won’t be noticed.
But if bleeding is constant and with certain intensity, it may appear an anaemia, with the progressive fatigue that goes with it. Depending on the destination of this blood, and on the bleeding intensity, the person with stomach cancer may realize the bleeding, due to the presence of one or both signs:
- Elimination of blood if done through the mouth, the person will vomit gastric content mixed with blood. This is called “hematemesis”.
- Blood elimination if done through the anus, the person may notice black stools during stomach bleeding caused by gastric cancer. These black stools are called “melena”.
When the tumour is already out of the stomach, it may be because it has escaped through one or more of these three ways:
- The tumour breaks peritoneum and goes to the abdominal cavity
- The tumour escapes through the lymphatics
- Or the tumour enters the blood stream.
When the tumour grows, it can break out the stomach wall. This rupture causes gastric cancer cells fall into the peritoneal cavity, and swimming in peritoneal fluid they end up settling on the surface of any abdominal viscera. Groups of cells can join and grow. These peritoneal implants can cause peritoneal irritation that will be perceived as symptoms of peritonitis, with diffuse abdominal pain.
“Peritoneal carcinomatosis” it is surface covered by the multiple growths of tumour implants on the peritoneal surface. If the tumour implants colonized the outer liver due to the dispersion of stomach cancer cells by the peritoneum. It will irritate the capsule that surrounds it. Due to the irritation caused by these implants, it may appear a localized pain in the upper right abdomen.
If tumour implants are placed in the outside wall of the small intestine, they can cause cessation of transit of intestinal contents. This is due to the compression of the tube from the outside. They produce a partial bowel obstruction, or a complete intestinal obstruction. Although not exclusive of stomach cancer, as it can appear in many tumours of the abdominal and pelvic viscera, when tumour cells travel to the navel they can settle there, originating lumps called “nodules of Sister Mary Joseph”. These lumps are clearly seen from the outside. Usually they are a sign that the cancer is in an advanced stage.
Stomach cancer cells, when choosing the lymphatic route to escape the body, tend to accumulate first on the lymph nodes surrounding the stomach itself. Because of this accumulation of tumour cells some symptoms can appear or become more pronounced causing nausea and vomiting. From lymph nodes close to the stomach, tumour cells can spread to more distant lymph regions, like the one situated behind the pancreas and peritoneum, and the region of the side of the aorta.
If they are in this area, most often they do not cause symptoms, but seldom they can cause pain nerve compression of neighbouring structures, such as the celiac plexus. The cells of stomach cancer can enter the blood stream because, within the cancer itself, some cells penetrate a blood vessel after breaking its wall.
Once in the blood, these stomach cancer cells can stay anywhere in the body, causing various symptoms depending on its location. The most common sites where stomach cancer that has escaped the blood can cause metastases are the liver, brain and lungs.
When stomach cancer cells go to the liver and begin to grow, they begin to crush healthy liver cells. If broken, liver contents, which are transaminases, will be poured into the blood stream.
This will increase their blood concentration (as detected in a blood test). If rapidly growing stomach cancer cells compress small channels within the liver that bile uses to travel, it can accumulate. This increases the indirect bilirubin concentration in the blood, which may condition that the skin gets a yellow tone. This phenomenon is called jaundice.
When groups of tumour cells start growing within the brain, they can form metastases, that will become increasingly large. By pushing neighbouring neurons, these neurons begin to function in an altered way, and therefore, two types of symptoms may occur:
- Irritative symptoms, in which neurons fire pushed uncontrolled flashes: for example, we can have epilepsy, convulsive crisis or not;
- Deficit symptoms, in which some neurons stop working and their work is not done we can have loss of mobility, loss of vision, lose feeling in any area of the body, and so on.
In both cases, if there is plenty of tumour in the head, as there is not enough room for so many cells because the skull is a closed cavity with a single large outlet, we can start having headaches. These headaches will gradually go up in intensity and frequency.
When tumour cells choose to live within the lungs, they usually form separate groups. Therefore, appearing multiple metastases. If they suppress enough lung function, difficulty breathing (a symptom called “dyspnoea”) can appear.
However, if they touch a breathing tube (bronchus or their branches), they can irritate them, appearing a very annoying dry cough. Coughing blood may occur if the blood vessel break due to the lung metastases locating near it.
Most often abdominal discomfort appears, which will become abdominal pain.
- If stomach cancer is located at the entrance of the stomach, it can cause difficulty passing food from the oesophagus to the stomach, or a gastroesophageal reflux may appear.
- If the cancer is at the outlet of the stomach into the small intestine, the person with stomach cancer may have nausea and vomiting when eating. When diffuse stomach cancer affects the entire gastric body, it can cause early satiety, so the person will eat less.
- Gradually eating less follow by sudden the weight loss. This will accentuated when the cachexia-anorexia syndrome develops. Even if the patient eats enough calories with the food.
- If the stomach lining breaks down, a bleeding will start, appearing black stools or vomiting with blood. Being anaemia will feel progressive fatigue.
Early satiety is often accentuated. This may lead to even nausea and vomiting as it gets worse. It is very rare, but abdominal pain can appear if retroperitoneal nerve plexus is affected.
If gastric cancer breaks the stomach wall and escapes through the peritoneum, it can produce:
- Pain in the liver area,
- Abdominal pain if peritonitis occurs, due to peritoneal carcinomatosis,
- Bowel obstruction if implants compress the wall of the small intestine.
- The appearance on the belly button of “nodules of Sister Mary Joseph”
- If it spreads using the bloodstream, most often there will be an increase in transaminases or indirect bilirubin concentrations.
- An infected Liver can cause Jaundice to appear.
- Once it also affects the brain, epileptic seizures or neurological deficits will occur.
- Or we can suffer cough, hemoptysis or dyspnea if metastases are in the lungs.
It is very important to know the symptoms of stomach cancer. Early detection of stomach cancer is the best way to beat it.