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□ Fig. 22 b.

sis, may be associated with a relatively insignificant invasion of the submucous membrane of the stomach. In addition, even in the presence of cancer infiltration over a short length, marked clinical symptoms may appear. But this relates only to tumors, the primary location of which is the pylorus proper [31, 222]. In patients with exophytic carcinoma, evacuation disorders develop mostly in cases where the tumor passes from the expansive growth stage to mixed-type cancer, which is associated with a strongly advanced process.

First, the evacuation disorders may occur only occasionally, especially in severe abuse of foods, especially bitter dishes or alcohol. The disorders are especially marked in patients who suddenly stop drinking strong alcoholic drinks to replace them with soft ones. Such patients may develop obstruction all of a sudden, while they are »totally healthy«. Epigastric pain and vomiting may develop. All these symptoms may persist for several days or weeks, and then subside as a result of dietary restrictions. The patient may feel healthy for several weeks or months, until another attack of obstruction occurs. In some patients, obstruction fails to be removed, but rather progresses steadily. Gradually increasing symptoms are more common. Even small meals cause an unsurpassable feeling of gravity in the stomach, and sometimes eructation. Voiding of gas through the mouth is explained by congestion of food in the stomach. The wind is first odorless, but later, as the congestion is characterized by putrefactive decomposition of the stomach contents, eructation becomes fetid, and the patient complains of »rotten-egg eructation«. Pyrosis (heartburn) is also not infrequent. This is due to irritation of the esophageal mucosa with regurgitated acid stomach contents. This may occur as well in the case of normal gastric secretion and also when organic acids are formed during decomposition of gastric contents. Therefore, hypoacidity patients with this complaint should undergo both an X-ray and endoscopic examination immediately, regardless of how recent their previous examination was (O Fig. 22).

O Fig. 22a-d. Patient D, age 54. Diagnosis: gastric cancer. Complained of overfilled stomach after eating very small meals, and of heartburn which persisted for 8 months. Slow but steady intensification of the symptoms led the patient to seek medical aid. a Stomach X-ray (tight filling, vertical position, anterior projection): the stomach contains much liquid, the antral part is disfigured, narrow, uneven walls are rigid (arrows), markedly disordered evacuation. b Stomach X-ray (double contract, horizontal position, right oblique projection): the pyloric and antral parts are disfigured and narrow, the walls are thick and rigid due to intramural circular infiltration (arrows). Conclusion: infiltrative cancer of the pyloric and antral parts of the stomach. c Macrospecimen of a resected stomach: the distal part is narrow, the walls are thick and firm (arrows). d Fragment of the macrospecimen (strip): the stomach wall is thick due to intramural infiltration (arrows). Histologically, an adenocarcinoma with the signet-ring cell component

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