Gastric cancer is the second most common cause of cancer death worldwide , being responsible for 650 000 deaths annually. In the UK in 2007, there were 5,236 deaths from stomach cancer, making it the seventh most common cause of cancer death and responsible for over 3% of all cancer related mortality . In 2007 the age-standardised rate of gastric carcinoma in the UK was 5.7 per 100 000 population.
The majority of the patients present with non-acute symptoms but gastric cancer can also manifest as an emergency with haematemesis, visceral perforation, or gastric outlet obstruction. Emergency presentation of gastric cancer has been shown to have an influence on overall survival, which is independent to any other factors. Blackshaw et al.  showed that patients presenting as an emergency had a median survival of 6 months, compared to 12 months for patients referred as an outpatient. Therefore, although emergency presentation is relatively rare, it may significantly affect prognosis.
Recent advances in diagnostic tools and new oncological treatments may improve the overall outcome of gastric carcinoma, but emergency presentation continues to be associated with higher stage of disease at presentation and lower rates of operability. The majority of the peer-reviewed papers report 10-25 patients in the emergency group [4–7].
Perforated gastric cancer is rare accounting for 0.3-3% of gastric cancer cases [6–8], but gastric cancer is present in 10-16% of patients presenting with gastric perforation . Only one-third of cases of perforated gastric cancer are diagnosed pre-operatively . The diagnosis of gastric cancer is usually confirmed by post-operative histological examination. A two-staged procedural approach is sometimes used for the treatment of perforated gastric carcinoma; the first procedure controls the perforation and treats peritonitis, followed by a second procedure involving definitive gastrectomy with appropriate lymph node dissection [10, 11].
Minor bleeding is a well-known characteristic of gastric cancer, often causing chronic microcytic hypochromic anaemia, prompting gastroscopy. However, gastric cancer can also present with major bleeding in up to 5% of patients . These patients may require blood transfusion to prevent haemodynamic compromise. Endoscopic therapy can be used to control bleeding with the use of injection of adrenaline to the tumour base, argon plasma coagulation or with application of endo-clips . However patients may require surgery for bleeding control if endoscopic measures for haemostasis fail.
Gastric outlet obstruction is more common than other emergency presentations and is usually a sign of locally advanced incurable disease. Traditionally, surgical bypass with gastrojejunostomy or palliative distal gastrectomy were the only therapeutic options to restore the gastric outflow. However increasingly, endoscopic stenting is utilised for to relieve obstruction in gastric cancer .
With specialist oesophagogastric surgeons being increasingly based in tertiary referral centres, there have been concerns that specialist surgeons may not be available should emergency surgical intervention be necessary in cases of gastric cancer. This raises the question of how commonly specialist oesophagogastric intervention is necessary in the emergency setting and how hospitals should plan their surgical service.