Eduovisual
Gastrointestinal
Gastric cancer: presentation and workup
— ~26,000 new US cases/year; 5-year survival ~36% overall, <7% for metastatic disease
— Global incidence highest in East Asia, Eastern Europe, Andean South America; immigrants retain elevated risk for ≥1 generation
— Median age at diagnosis ~68; male:female ~2:1; Black, Hispanic, Asian, and Native American patients disproportionately affected in the US
— Intestinal type (Lauren): older patients, distal/antral, linked to H. pylori, atrophic gastritis, smoking, salt/nitrates, pickled foods
— Diffuse type (Lauren): younger patients, signet-ring cells, linitis plastica, worse prognosis, associated with CDH1 germline mutations (hereditary diffuse gastric cancer)
— Proximal/cardia adenocarcinoma behaves more like esophageal cancer (GERD, obesity, Barrett's)
— H. pylori (intestinal type, distal); EBV; chronic atrophic gastritis; pernicious anemia; partial gastrectomy >15 years prior
— Smoking, high-salt/smoked food diet, obesity (cardia)
— Family history; Lynch syndrome, FAP, Peutz-Jeghers, Li-Fraumeni, juvenile polyposis
— Blood group A (modest)
— New dyspepsia in adult ≥60 OR dyspepsia at any age with alarm features ("ALARMS-55"): Anemia, Loss of weight, Anorexia, Recent onset/progressive, Melena/hematemesis, Swallowing difficulty, age >55
— Iron-deficiency anemia in a man or postmenopausal woman without an obvious source
— Early satiety, persistent vomiting, epigastric mass
Board pearl: Any adult ≥60 with new-onset dyspepsia, or any age with alarm features, gets prompt EGD — not an empiric PPI trial. Empiric acid suppression in a stem with weight loss + anemia is the wrong answer and will mask malignancy.
Step 3 management: Document a focused alarm-feature review at every dyspepsia visit; this is the ambulatory decision point that determines who gets scoped versus test-and-treat for H. pylori.
— Epigastric pain or "ulcer-like" dyspepsia unrelieved by PPI
— Unintentional weight loss (>5% in 6 months) — present in ~60% at diagnosis
— Early satiety, postprandial fullness, nausea
— Anorexia, particularly aversion to meat
— Occult or overt GI bleeding: melena, hematemesis, iron-deficiency anemia
— Dysphagia (proximal/GE junction tumors); vomiting (distal/pyloric obstruction)
— Trousseau syndrome: migratory superficial thrombophlebitis
— Acanthosis nigricans and the sign of Leser-Trélat (sudden eruptive seborrheic keratoses)
— Dermatomyositis, membranous nephropathy
— Microangiopathic hemolytic anemia (MAHA) — mucinous adenocarcinomas
— DIC, nonbacterial thrombotic endocarditis
— Duration and trajectory of dyspepsia; response (or non-response) to prior PPI
— Prior H. pylori testing/treatment and confirmation of eradication
— Tobacco, alcohol, dietary pattern (salt, smoked/pickled foods, low fresh produce)
— Country of origin and age at immigration (East Asia, Andean SA, E. Europe)
— Family history of gastric, breast (lobular), colon, endometrial, pancreatic cancers — screen for CDH1 and Lynch
— Prior gastric surgery (Billroth II — stump cancer risk)
— Pernicious anemia, autoimmune gastritis, prior gastric polyps or intestinal metaplasia
— Functional dyspepsia improves or fluctuates; gastric cancer dyspepsia is progressive and PPI-refractory
— Weight loss and anemia are not features of functional dyspepsia — their presence reframes the workup
Key distinction: H. pylori-driven peptic ulcer pain often improves with eating (duodenal) or worsens with eating (gastric ulcer/cancer). A "gastric ulcer" that doesn't heal on 8–12 weeks of PPI must be rebiopsied — non-healing ulcer is malignant until proven otherwise.
Board pearl: Leser-Trélat + new dyspepsia → think gastric adenocarcinoma; order EGD, not a dermatology biopsy first.
— Cachexia, temporal wasting, sarcopenia — quantify with weight trend and BMI
— Orthostatic vitals if GI bleeding suspected; tachycardia + pallor may be the only sign of slow upper GI blood loss
— Pale conjunctivae, koilonychia, glossitis suggest chronic iron deficiency
— Palpable epigastric mass in 30–50% of advanced cases — firm, often fixed
— Succussion splash > 3 hours postprandial → gastric outlet obstruction (distal antral tumor)
— Hepatomegaly with nodular edge → liver metastases
— Ascites with shifting dullness → peritoneal carcinomatosis
— Virchow node: left supraclavicular lymphadenopathy (thoracic duct drainage)
— Sister Mary Joseph nodule: periumbilical mass from peritoneal spread along falciform ligament
— Krukenberg tumor: bilateral ovarian metastases (signet-ring cells) — adnexal fullness on pelvic exam
— Blumer shelf: palpable mass in the rectouterine/rectovesical pouch on DRE
— Irish node: left axillary lymphadenopathy (less common)
— Acanthosis nigricans (axillae, neck, knuckles — "tripe palms")
— Leser-Trélat: explosive crop of seborrheic keratoses on trunk
— Migratory thrombophlebitis on calves/thighs
— Heliotrope rash, Gottron papules if dermatomyositis
— Shock index (HR/SBP) >1 → consider active bleed, type & cross, ICU-level monitoring
— Capillary refill, mental status, urine output as endpoints
Board pearl: Always perform a DRE and palpate the left supraclavicular fossa in any patient worked up for gastric cancer — Virchow node, Sister Mary Joseph nodule, and Blumer shelf are stem-defining findings that immediately upstage to M1 disease.
Step 3 management: A bedside pelvic exam in women with suspected gastric cancer identifies Krukenberg metastases and changes staging strategy — this is the kind of cross-specialty exam the CCS rewards.
— CBC: microcytic anemia (chronic blood loss) is the most common abnormality; check MCV, RDW
— Iron studies: low ferritin, low Fe, high TIBC — confirm IDA before attributing anemia to chronic disease
— CMP: albumin (nutritional status, prognostic), LFTs (liver mets), BUN/Cr
— LDH: elevated with bulky disease or hemolysis (MAHA)
— Coags (PT/INR, PTT) — baseline before endoscopy/biopsy and to detect DIC
— Fecal occult blood/FIT: often positive but a negative test does NOT exclude
— Consider B12 if pernicious anemia/autoimmune gastritis suspected
— CEA, CA 19-9, CA 72-4 are NOT screening or diagnostic tests
— Used for post-treatment surveillance when elevated at baseline
— A normal CEA does not exclude gastric cancer; never reassure on this basis
— Stool antigen or urea breath test (off PPI ≥2 weeks, off antibiotics ≥4 weeks)
— At endoscopy: rapid urease test on biopsy, histology — both more sensitive in bleeding patients
— Confirm eradication 4 weeks after therapy in all cancer/MALT-related cases
— Plain films and upper GI barium series are largely historical; "linitis plastica" appearance on barium is classic but EGD is the modern first study
— Outpatient CT before tissue diagnosis is acceptable when bulk disease is obvious but should not delay EGD
— EGD with biopsy is the diagnostic gold standard — obtain ≥6–8 biopsies from the ulcer rim and base (single biopsy sensitivity ~70%, ≥7 approaches 98%)
— Brush cytology adds yield in linitis plastica where mucosa looks normal
Board pearl: A gastric ulcer on EGD requires biopsy every time, even if it looks benign. Duodenal ulcers do not require routine biopsy because malignancy is rare.
Step 3 management: Order EGD before CT in a stable outpatient with alarm dyspepsia — tissue diagnosis drives every subsequent decision, including whether to stage at all.
— Goal is to separate resectable (Stage I–III) from unresectable/metastatic (Stage IV)
— Multimodal staging because no single test captures all spread patterns
— First staging study after diagnosis
— Assesses primary depth, regional nodes, liver/lung/adrenal mets, ascites, peritoneal stranding
— Sensitivity for peritoneal disease only ~30–50% — a "clean" CT does not exclude carcinomatosis
— Best modality for T and N staging of the locoregional tumor
— Determines depth of invasion (T1a mucosal vs T1b submucosal vs deeper) — decides whether endoscopic resection (ESD/EMR) is feasible
— FNA of suspicious perigastric/celiac nodes
— Selective use; helpful for distant nodal/metastatic disease when CT is equivocal
— Signet-ring and mucinous tumors are often FDG-non-avid — limits sensitivity
— Not for primary T staging
— Indicated for clinical T3/T4 or N+ disease without obvious M1 on imaging, before committing to gastrectomy
— Detects radiographically occult peritoneal carcinomatosis in 20–30%
— Positive cytology = M1 (Stage IV) even without visible implants — changes intent from curative to palliative/systemic
— HER2 (IHC ± FISH) — trastuzumab eligibility
— PD-L1 CPS — nivolumab/pembrolizumab eligibility
— MSI/MMR — immunotherapy benefit, Lynch screen
— Claudin 18.2 — zolbetuximab eligibility
— EBV status, NTRK in select cases
Board pearl: Positive peritoneal cytology on laparoscopic washings = Stage IV, even with normal CT and no visible implants. The right answer is systemic therapy, not gastrectomy.
Key distinction: EUS stages the tumor depth and local nodes; CT/PET/laparoscopy stage distant spread. You need both axes before a treatment plan.
— Tis / T1a (intramucosal): endoscopic resection (EMR or ESD) if well-differentiated, ≤2 cm, no ulceration, no LVI
— T1b–T2 N0: upfront surgery (subtotal or total gastrectomy with D2 lymphadenectomy)
— T3–T4 or N+, M0 (resectable locally advanced): perioperative chemotherapy (FLOT) sandwiching gastrectomy
— M1 / unresectable: palliative systemic therapy ± targeted/immunotherapy; best supportive care
— Distal/antral tumors → subtotal gastrectomy (preserves remnant, better QoL)
— Proximal or diffuse-type → total gastrectomy with Roux-en-Y reconstruction
— Minimum 15 lymph nodes examined for adequate staging; D2 lymphadenectomy is standard at high-volume US centers
— Negative margins (R0) is the goal; diffuse-type often requires wider margins (≥5 cm)
— ECOG 0–1: full multimodal candidate
— ECOG 2: modified regimens, doublets, geriatric assessment
— ECOG 3–4: palliative only; focus on symptom control
— Albumin <3.0, >10% weight loss, sarcopenia → preoperative nutritional support 7–14 days improves outcomes
— Enteral preferred over parenteral; consider jejunal feeding tube at staging laparoscopy
— Surgical oncology, medical oncology, radiation oncology, GI, pathology, nutrition, palliative care all weigh in before committing to a path
Step 3 management: For locally advanced resectable gastric adenocarcinoma, the correct sequence is perioperative FLOT → gastrectomy with D2 → completion FLOT, not surgery followed by adjuvant chemo alone. Neoadjuvant improves R0 rates and survival.
Board pearl: Endoscopic submucosal dissection (ESD) is curative for early gastric cancer that meets size, differentiation, depth, and ulceration criteria — surgery is not always required.
— Fluorouracil + Leucovorin + Oxaliplatin + Docetaxel q2 weeks × 4 cycles pre-op and × 4 cycles post-op
— Superior to ECF/ECX (epirubicin-based) in OS and pathologic response (FLOT4 trial)
— Toxicities: neutropenia (G-CSF support), neuropathy (oxaliplatin), mucositis, diarrhea
— Capecitabine + oxaliplatin (CAPOX) × 6 months, or
— Adjuvant chemoradiation (5-FU/leucovorin) per Intergroup 0116 — used when <D2 dissection or positive margins
— Backbone: fluoropyrimidine (5-FU or capecitabine) + platinum (oxaliplatin or cisplatin)
— Add nivolumab if PD-L1 CPS ≥5 (CheckMate 649) — survival benefit
— Add trastuzumab if HER2-positive (IHC 3+ or 2+/FISH+) — ToGA trial; consider trastuzumab deruxtecan in later lines
— Add zolbetuximab if claudin 18.2-positive (SPOTLIGHT, GLOW)
— Pembrolizumab monotherapy for MSI-high tumors
— Ramucirumab (VEGFR2 mAb) + paclitaxel — RAINBOW trial
— Trifluridine-tipiracil (TAS-102) for ≥3rd line
— Trastuzumab deruxtecan for HER2+ post-progression
— Check DPYD variants before fluoropyrimidines — severe toxicity risk
— Echo/MUGA before trastuzumab; avoid if LVEF <50%
— Hypomagnesemia, hypocalcemia with cetuximab-class agents (not standard in gastric, but tested)
— Renal dose-adjust capecitabine and cisplatin
Board pearl: Every newly diagnosed metastatic gastric adenocarcinoma needs HER2, PD-L1 CPS, MMR/MSI, and claudin 18.2 testing before first-line therapy — these four biomarkers determine which targeted/immune agent gets added to the chemo backbone.
Step 3 management: Order baseline echo and DPYD genotyping before initiating FLOT — anticipating toxicity is a Step 3 ambulatory-oncology skill.
— EMR/ESD curative for select early cancers (T1a, well-diff, ≤2 cm, no ulceration, no LVI)
— Surveillance EGD q3–6 months × first year post-ESD, then annually
— Hemostasis for bleeding tumors: epinephrine injection, clips, argon plasma coagulation, hemospray
— Palliative stenting for malignant gastric outlet obstruction or proximal dysphagia — self-expanding metal stents (SEMS); preferred over gastrojejunostomy in short life expectancy (<6 months)
— Subtotal gastrectomy: distal tumors, ≥5 cm proximal margin
— Total gastrectomy with Roux-en-Y esophagojejunostomy: proximal, mid-body, or diffuse-type
— D2 lymphadenectomy — perigastric + celiac/hepatic/splenic stations; ≥15 nodes examined
— Minimally invasive (lap/robotic) acceptable at experienced centers for distal tumors
— Prophylactic total gastrectomy offered to CDH1 carriers between ages 20–30 — diffuse-type cancer often undetectable endoscopically
— Gastrojejunostomy (surgical bypass) for outlet obstruction with longer prognosis
— Venting gastrostomy for malignant bowel obstruction/peritoneal disease
— Celiac plexus neurolysis for refractory pain
— Radiation for bleeding or pain palliation (single fraction or short course)
— Hold antiplatelets/anticoagulants per ASGE guidelines before biopsy/ESD
— VTE prophylaxis is essential — gastric cancer is highly thrombogenic (Trousseau)
— Nutritional optimization 7–14 days pre-op; jejunal feeding tube at surgery
— Enhanced recovery after surgery (ERAS) protocols reduce LOS
CCS pearl: For a patient with gastric outlet obstruction from advanced cancer and ECOG 3, the right CCS sequence is: NPO → NG decompression → IV fluids + electrolyte correction (hypochloremic hypokalemic metabolic alkalosis) → endoscopic SEMS placement → resume oral intake → palliative care consult.
Board pearl: CDH1+ patients should be offered prophylactic total gastrectomy, not surveillance EGD alone — diffuse-type cancer arises beneath normal-appearing mucosa.
— Median age at diagnosis ~68; many present at 75+ with comorbidity
— Use a comprehensive geriatric assessment (CGA) — G8 screen, then full CGA if abnormal
— Evaluate cognition (MoCA), function (ADLs/IADLs), nutrition (MNA), comorbidity (CCI), polypharmacy, social support
— Chronologic age alone does not preclude curative therapy; biologic age and reserve do
— Subtotal gastrectomy tolerated better than total — preserve remnant when oncologically safe
— Higher 90-day mortality at low-volume centers — refer to high-volume regional center
— Prehabilitation (exercise, nutrition, smoking cessation) 2–4 weeks pre-op reduces complications
— Replace FLOT (4-drug, toxic) with doublet FOLFOX or CAPOX in ECOG 2 or age >75
— Reduce doses 20–25% upfront, escalate with tolerance
— G-CSF primary prophylaxis if febrile neutropenia risk >20%
— Avoid cisplatin in CrCl <60; substitute oxaliplatin
— Capecitabine: reduce 25% if CrCl 30–50; contraindicated <30
— Cisplatin: avoid if CrCl <60; aggressive hydration, Mg/K repletion when used
— 5-FU: minimal renal clearance, generally safe
— Oxaliplatin: caution if CrCl <30
— Ramucirumab: no renal adjustment but monitor proteinuria; hold if >2 g/24h
— Docetaxel and paclitaxel: avoid or reduce if bilirubin >1.5× ULN, AST/ALT elevated
— Trastuzumab: hepatic mets common; monitor LFTs and LVEF
— Child-Pugh B/C → palliative intent, single-agent or best supportive care
Step 3 management: Before starting any cytotoxic in an older adult, calculate CrCl, perform G8/CGA, reconcile medications, baseline echo, and document goals of care. These are the recurring ambulatory-oncology vignettes on Step 3.
Board pearl: A "fit 80-year-old" can receive curative-intent surgery and modified chemo; a "frail 65-year-old" with sarcopenia and CCI ≥5 may not — function trumps age.
— Gastric cancer in pregnancy is rare but devastating — symptoms (nausea, reflux, anemia) overlap with normal pregnancy, causing diagnostic delay
— EGD with biopsy is safe in all trimesters; preferred over imaging
— MRI without gadolinium acceptable for staging; avoid CT and PET
— Management individualized: surgery feasible in 2nd trimester; chemotherapy (5-FU, oxaliplatin) generally avoided in 1st trimester but possible 2nd/3rd
— Multidisciplinary discussion with maternal-fetal medicine, oncology, ethics
— Autosomal dominant; lifetime gastric cancer risk ~70% men, ~56% women by age 80
— Also: lobular breast cancer (~40% women), cleft lip/palate
— Criteria for testing: 2 cases gastric cancer in family with ≥1 diffuse-type; diffuse gastric cancer <50; diffuse gastric + lobular breast cancer in same person or family
— Management: prophylactic total gastrectomy ages 20–30 OR annual surveillance EGD with random biopsies (less effective); annual breast MRI for women
— Lynch syndrome (MMR mutations): 5–10% gastric cancer risk; EGD with H. pylori eradication starting age 30–35
— FAP: gastric fundic gland polyps (usually benign) but duodenal/ampullary cancer risk dominates
— Peutz-Jeghers (STK11): ~29% gastric cancer risk; mucocutaneous pigmentation
— Li-Fraumeni (TP53), juvenile polyposis (SMAD4/BMPR1A): included in HDGC differential
— GAPPS (gastric adenocarcinoma and proximal polyposis of stomach): APC promoter 1B mutation
— Extremely rare; when present, often associated with hereditary syndrome — refer to genetics
— Higher proportion of diffuse-type; consider CDH1, Li-Fraumeni testing
Board pearl: Any patient <40 with diffuse-type gastric adenocarcinoma, or any family with ≥2 gastric cancers (≥1 diffuse), gets germline CDH1 testing and cascade testing of first-degree relatives.
Key distinction: Lynch syndrome → intestinal-type, distal gastric cancer; HDGC/CDH1 → diffuse-type, infiltrative — different histology, different surveillance.
— Upper GI bleeding (overt or occult) — most common; iron-deficiency anemia, melena, hematemesis
— Gastric outlet obstruction — distal/antral tumors; succussion splash, postprandial vomiting, hypochloremic hypokalemic metabolic alkalosis
— Perforation — uncommon; acute peritonitis, free air on imaging
— Dysphagia — proximal/cardia tumors
— Malnutrition and cachexia — sarcopenia, hypoalbuminemia drive perioperative mortality
— Peritoneal carcinomatosis → malignant ascites, bowel obstruction
— Liver metastases → hepatic failure, biliary obstruction
— Krukenberg → pelvic pain, ovarian torsion
— Trousseau syndrome / VTE — anticoagulate with LMWH or DOAC (apixaban, edoxaban acceptable per Caravaggio/Hokusai-VTE Cancer)
— DIC, MAHA, nonbacterial thrombotic endocarditis with embolic stroke
— Hypercalcemia of malignancy (rare)
— Post-gastrectomy syndromes: dumping syndrome (early and late), afferent loop syndrome, bile reflux gastritis, alkaline reflux esophagitis
— Nutritional deficiencies after gastrectomy: B12 (lifelong IM injections after total gastrectomy), iron, calcium, vitamin D, folate
— Anastomotic leak (5–10% after total gastrectomy) — fever, tachycardia, leukocytosis POD 4–7 → CT with oral contrast
— Chemotherapy: febrile neutropenia, neuropathy, mucositis, cardiotoxicity (trastuzumab)
— Stent migration, occlusion, perforation
— Small frequent meals (6–8/day), protein-first, separate liquids from solids
— Pancreatic enzyme replacement for fat malabsorption
Step 3 management: After total gastrectomy, prescribe lifelong parenteral B12 (1000 mcg IM monthly), oral iron, calcium + vitamin D, and a daily multivitamin. Annual labs: CBC, ferritin, B12, vitamin D, DEXA at 2 years.
Board pearl: Tachycardia and unexplained leukocytosis on POD 5 after gastrectomy = anastomotic leak until proven otherwise — get CT with oral water-soluble contrast, not just labs.
— Hemodynamically significant GI bleed: shock index >1, Hb drop ≥2 g/dL, hematemesis with active bleeding → admit ICU, large-bore IV ×2, type & cross 4 units, IV PPI, urgent EGD within 24h
— Gastric outlet obstruction with intractable vomiting: admit for NG decompression, IV fluids, electrolyte correction, urgent endoscopy
— Perforation: peritoneal signs + free air → emergent surgical consult, broad-spectrum antibiotics (piperacillin-tazobactam), NPO, IV resuscitation
— Malignant bowel obstruction from carcinomatosis: NG decompression, octreotide, dexamethasone, palliative care consult
— Febrile neutropenia on chemo: ANC <500 + T ≥38.3 → admit, blood cultures ×2, cefepime within 1 hour (MASCC score guides outpatient eligibility)
— GI: all suspected upper GI bleeds, suspicious EGD findings, stenting decisions
— Surgical oncology: resectable disease, obstruction, perforation
— Medical oncology: tissue-confirmed cancer for systemic therapy planning
— Radiation oncology: palliation of bleeding or pain, select adjuvant cases
— Interventional radiology: biliary stenting, drainage of malignant ascites
— Palliative care: early integration improves QoL and survival (Temel paradigm extends to GI cancers)
— Nutrition: any >10% weight loss, pre-op optimization, post-gastrectomy
— Genetics: any patient meeting HDGC/Lynch criteria
— Massive UGIB with ongoing transfusion requirement
— Septic shock from perforation or febrile neutropenia
— Postoperative complications: leak with sepsis, respiratory failure
CCS pearl: A new gastric cancer patient with hematemesis and SBP 88: on CCS, order — 2 large-bore IVs, NS bolus, T&C 4U PRBC, IV pantoprazole 80 mg bolus then 8 mg/h drip, NPO, urgent GI consult, ICU admission, octreotide if variceal coexistence suspected, transfuse to Hb >7 (>8 if cardiac disease).
Board pearl: Early palliative care referral at metastatic diagnosis (not at end of life) improves both QoL and survival — this is a tested USMLE concept.
— Caused by H. pylori or NSAIDs; epigastric pain, often nocturnal
— Heals on 8–12 weeks PPI; non-healing ulcer = rebiopsy for cancer
— Distinguish from malignant ulcer: location (lesser curve more suspicious), rolled edges, friability, non-healing
— No alarm features, normal EGD, fluctuating symptoms
— Rome IV criteria: postprandial distress and/or epigastric pain syndrome ≥3 months
— Test-and-treat H. pylori, then PPI trial
— Strongly H. pylori-associated
— Stage IE/IIE treated with H. pylori eradication alone — 70–80% achieve remission
— Endoscopic appearance: thickened folds, nodularity, ulceration — can mimic adenocarcinoma
— Biopsy distinguishes; immunohistochemistry shows B-cell markers
— Submucosal mass with normal overlying mucosa (mucosal biopsy often non-diagnostic)
— c-KIT (CD117) positive; imatinib is first-line for unresectable/metastatic
— EUS-guided FNA preferred over mucosal biopsy
— Type 1 (most common): chronic atrophic gastritis/pernicious anemia, hypergastrinemia; usually indolent
— Type 2: Zollinger-Ellison/MEN1
— Type 3: sporadic, aggressive — treat like adenocarcinoma
— Hypertrophic gastropathy with giant rugal folds, protein-losing enteropathy
— Hypoalbuminemia, peripheral edema
— Increased cancer risk; surveillance EGD
— Fundic gland (PPI-associated, FAP), hyperplastic, adenomatous (preneoplastic — remove)
Key distinction: A submucosal mass with normal overlying mucosa on EGD → think GIST or NET, not adenocarcinoma. Order EUS with FNA rather than repeating mucosal biopsies.
Board pearl: Gastric MALT lymphoma localized to the stomach can be cured by H. pylori eradication alone — no chemotherapy or surgery needed in early-stage disease. Confirm eradication and remission by repeat EGD.
— Painless jaundice (head of pancreas), weight loss, new-onset diabetes >50
— Trousseau syndrome shared with gastric cancer
— CA 19-9 elevated; CT pancreas protocol; EUS-FNA
— Differentiates by imaging — pancreatic mass vs gastric wall thickening
— RUQ pain, jaundice, weight loss
— MRCP, ERCP with brushings
— Risk factors: PSC, choledochal cysts, liver flukes
— GERD, Barrett's, obesity; dysphagia is hallmark (solids then liquids)
— GE junction tumors (Siewert classification) bridge esophageal and gastric — treated as one or the other based on epicenter
— Cirrhosis background, RUQ pain, weight loss
— AFP, multiphase CT/MRI (arterial enhancement with washout)
— B symptoms (fever, night sweats, weight loss), lymphadenopathy
— LDH elevated; biopsy of accessible node
— "Food fear," postprandial pain, weight loss — overlaps clinically
— Atherosclerotic risk factors; CT angiography
— Weight loss, early satiety, food restriction in young patients
— Distinguish by psychosocial history, body image, normal EGD
— Weight loss without GI lesion
— TSH, AM cortisol, PHQ-9
— Weight loss, anorexia in endemic areas or immunosuppressed
— Gastric TB rare but mimics malignancy on EGD
Step 3 management: Unintentional weight loss workup in a primary care visit: CBC, CMP, TSH, HIV, age-appropriate cancer screening (mammogram, colonoscopy, low-dose CT if smoker), CXR, U/A, plus EGD if any upper GI symptoms or unexplained iron-deficiency anemia.
Key distinction: Painless jaundice + weight loss → pancreatic head cancer; weight loss + early satiety + anemia → gastric cancer; dysphagia + reflux history → esophageal cancer. Imaging localizes; biopsy confirms.
— PPI (omeprazole 20 mg daily) for 4–8 weeks then taper; lifelong if reflux esophagitis post-total gastrectomy
— Lifelong vitamin B12 1000 mcg IM monthly (or 1000 mcg PO daily) after total gastrectomy; check level annually
— Iron supplementation (ferrous sulfate 325 mg daily with vitamin C)
— Calcium 1200 mg + vitamin D 800–2000 IU daily to prevent metabolic bone disease
— Multivitamin including folate, zinc, copper
— VTE prophylaxis: extended LMWH or DOAC × 4 weeks post-major abdominal cancer surgery (per ASCO/NCCN)
— Small frequent meals (6–8/day), high protein, low simple carbohydrates
— Separate liquids from solids by 30 minutes (dumping prevention)
— Avoid alcohol initially; tobacco cessation absolute
— Pancreatic enzyme replacement if steatorrhea
— Quadruple therapy (bismuth, PPI, tetracycline, metronidazole) × 14 days or
— Clarithromycin-based triple only if local resistance <15% (uncommon in US now)
— Confirm eradication with urea breath or stool antigen 4 weeks after therapy
— Cancer survivors have elevated CV mortality — manage BP, lipids, diabetes, smoking
— Cardio-oncology referral if anthracycline or trastuzumab exposure
— Refer any HDGC/Lynch/Peutz-Jeghers candidate to genetics
— First-degree relatives: testing, surveillance EGD, breast MRI as indicated
— Annual influenza, COVID boosters, pneumococcal (PCV20 or PCV15→PPSV23), RSV, shingles (age ≥50)
Step 3 management: At every survivorship visit, reconcile B12, iron, calcium, vitamin D, DEXA every 2 years, and reinforce dietary structure — post-gastrectomy patients fail without this longitudinal scaffolding.
Board pearl: Confirm H. pylori eradication 4 weeks after completing therapy, off PPI ≥2 weeks. Don't re-treat empirically — pick a different regimen based on susceptibility if available.
— History and physical every 3–6 months × 1–2 years, then every 6–12 months × years 3–5, then annually
— CBC, CMP at each visit
— CT chest/abdomen/pelvis every 6–12 months × 2 years, then annually × 5 years for stage II–III
— EGD as clinically indicated (mandatory after endoscopic resection or subtotal gastrectomy with remaining stomach) — q6–12 months × 2 years post-ESD
— Tumor markers (CEA, CA 19-9, CA 72-4) only if elevated at baseline
— Nutritional labs annually: B12, iron, ferritin, vitamin D, calcium, folate, zinc
— DEXA scan at 2 years post-total gastrectomy
— EGD at 3, 6, 12 months, then annually
— Eradicate H. pylori — reduces metachronous cancer risk by ~50%
— Restaging CT every 8–12 weeks on systemic therapy
— Reassess goals of care at each progression
— Physical therapy / cancer rehab program — improves sarcopenia, fatigue
— Nutritionist-led counseling for first 6 months post-op (and ongoing if weight loss continues)
— Dumping syndrome management: dietary first; octreotide if refractory
— Mental health: depression and anxiety affect 30–40% — PHQ-9, GAD-7 at visits
— Expected weight loss 10–15% post-total gastrectomy, plateau by 6–12 months
— Report new dysphagia, hematemesis, melena, jaundice, abdominal pain — recurrence symptoms
— Return to work timeline 8–12 weeks for open gastrectomy, 4–6 weeks for laparoscopic
Step 3 management: Set the follow-up cadence at discharge and schedule the first oncology visit before the patient leaves the hospital. Loss-to-follow-up after major cancer surgery is a tested patient safety failure mode.
Board pearl: Eradicating H. pylori after endoscopic resection of early gastric cancer reduces metachronous cancer risk — always confirm and re-treat if persistent.
— Specifically disclose: 30-day mortality (2–5% for total gastrectomy), anastomotic leak, lifelong nutritional changes, dumping, B12 dependence, fertility implications (chemotherapy gonadotoxicity)
— Use teach-back; document in patient's preferred language with qualified medical interpreter (not family members) — violation of interpreter standards is a recurring Step 3 safety pitfall
— Capacity assessment if delirium, severe pain, or cognitive impairment present
— Prophylactic total gastrectomy in a 25-year-old asymptomatic carrier requires genetic counseling, psychological support, fertility discussion
— Cascade testing involves disclosure to relatives — patient is encouraged but not required to inform
— Insurance: GINA protects against health insurance and employment discrimination but not life, disability, or long-term care insurance — must disclose this gap
— Metastatic gastric cancer median OS ~12 months — early ACP conversation
— Document code status, healthcare proxy, POLST/MOLST as appropriate
— Early palliative care integration is standard, not "giving up"
— Highest-risk handoffs: hospital → SNF, surgical service → oncology, oncology → primary care survivorship
— Medication reconciliation at every transition; specifically verify B12, iron, PPI, anticoagulation
— Written survivorship care plan to PCP within 6 months of completing treatment
— Equitable access — language, transportation, insurance barriers disproportionately exclude minority patients
— Document trial discussion in metastatic disease
— Cancer registry reporting required by state law
— Adverse events from chemo (febrile neutropenia, deaths) reported per institutional policy and FDA MedWatch
Board pearl: Using a patient's adult child as a medical interpreter for a complex oncology consent is a wrong answer on Step 3 — use a certified medical interpreter even if it delays the conversation.
Step 3 management: At metastatic diagnosis, simultaneously initiate systemic therapy AND palliative care + advance care planning — not sequentially. Parallel tracks improve outcomes and satisfaction.
— Virchow node — left supraclavicular
— Sister Mary Joseph nodule — periumbilical
— Krukenberg tumor — bilateral ovarian, signet-ring
— Blumer shelf — palpable on DRE (rectouterine/rectovesical pouch)
— Irish node — left axillary
— Trousseau syndrome — migratory thrombophlebitis
— Acanthosis nigricans + tripe palms
— Leser-Trélat sign — eruptive seborrheic keratoses
— Dermatomyositis, membranous nephropathy, MAHA, DIC
— Smoking / Salt-cured foods
— Autoimmune gastritis / Atrophic gastritis
— Low fruits/veggies, H. pylori infection (low socioeconomic)
— Type A blood / Pernicious anemia / Prior gastric surgery (Billroth II)
— Intestinal type → distal, H. pylori, older patients, hematogenous spread to liver
— Diffuse type → linitis plastica, signet-ring cells, CDH1, younger, peritoneal spread
— Signet-ring on biopsy in young patient → CDH1 testing
— HER2, PD-L1 CPS, MMR/MSI, claudin 18.2
— Locally advanced: perioperative FLOT
— Metastatic HER2+: add trastuzumab
— Metastatic PD-L1 CPS ≥5: add nivolumab
— Metastatic MSI-H: pembrolizumab
— Localized MALT lymphoma: H. pylori eradication alone
— Early T1a meeting criteria: ESD
— CDH1 carriers: prophylactic total gastrectomy
— Diffuse-type doesn't form a discrete mass → biopsy linitis plastica with multiple deep samples + brushings
— Total gastrectomy → Roux-en-Y esophagojejunostomy
Board pearl: Signet-ring carcinoma + family history + age <50 = think CDH1, refer to genetics, screen relatives, discuss prophylactic gastrectomy.
Key distinction: Intestinal-type spreads hematogenously to liver; diffuse-type spreads transcoelomically to peritoneum and ovaries.
— 62-year-old with 3 months of epigastric pain, 8-kg weight loss, microcytic anemia
— Wrong answers: empiric PPI trial, H. pylori test-and-treat alone, reassurance
— Right answer: prompt EGD with biopsy
— Patient with gastric ulcer on prior EGD, completed 8 weeks of PPI, repeat EGD shows persistent ulcer
— Wrong: extend PPI, double the dose, switch to H2 blocker
— Right: repeat biopsies (≥6–8) of ulcer rim and base
— 68-year-old man, Hb 9.1, ferritin 8, no obvious source, colonoscopy normal
— Right: EGD with duodenal biopsies (celiac) and gastric inspection/biopsy
— Patient with epigastric pain + palpable left supraclavicular node
— Right: EGD with biopsy; staging CT; FNA of node confirms metastasis
— EGD shows thickened, rigid gastric folds without discrete mass; superficial biopsies negative
— Right: deep/jumbo biopsies + brush cytology; consider EUS-guided FNA
— Mother had lobular breast cancer, aunt had stomach cancer
— Right: CDH1 germline testing, refer to genetics
— T3N1M0 distal gastric cancer in fit patient
— Right: perioperative FLOT → subtotal gastrectomy with D2 → completion FLOT
— Staging laparoscopy washings positive, no visible peritoneal disease
— Right: systemic therapy (Stage IV), not gastrectomy
— Macrocytic anemia, low B12
— Right: lifelong B12 supplementation
— Right: triple/quadruple H. pylori eradication alone; repeat EGD to confirm remission
Board pearl: When the stem gives you alarm features in an adult, your reflex answer is EGD with biopsy — empiric medical therapy is the distractor designed to fail you.
Step 3 management: Match the stage to the treatment intent first, then choose the specific regimen — this prevents picking surgery in metastatic patients or chemo-only in resectable ones.
Gastric adenocarcinoma is a stealth disease that presents late with dyspepsia, weight loss, and iron-deficiency anemia — diagnose it by promptly scoping any adult ≥60 with new dyspepsia or any age with alarm features, biopsy generously, stage with CT + EUS + diagnostic laparoscopy with peritoneal washings, biomarker-test (HER2, PD-L1, MMR, claudin 18.2), and treat locally advanced disease with perioperative FLOT plus D2 gastrectomy while reserving palliative systemic therapy for Stage IV.
Board pearl: The single most tested teaching point is the alarm-feature trigger for EGD — empiric PPI in a patient with weight loss and anemia is always the wrong answer on Step 3.