INTRODUCTION
Name : Mr A
Age :
59 years old
Gender : Male
Race : Malay
Occupation : Pensioner
Address : Jalan Prima Setapak, Setapak, Kuala Lumpur
Date of admission : 23 March 2018
Date of clerking : 25 March 2018
CHIEF
COMPLAINT
Patient comes to the hospital due
to per rectal bleeding for 1 month.
HISTORY
OF PRESENTING ILLNESS
Patient was apparently well until 5
months ago, when he experienced abdominal pain that is generalized as he unable
to pinpoint the location of the pain. The pain was sudden in onset, colicky in
nature and gradually increasing in severity. However, he still able to tolerate
the pain and it did not affect his daily activities. Around 3 months after the
onset of the symptom, the pain which is initially generalized had radiated to
the epigastric region. The pain had been burning in nature and aggravated by
food ingestion especially spicy and salty food. He then went to a nearby Klinik
Kesihatan and was prescribed with a medication. The symptom was noted to be relieved
by the medication. There was no episode of nausea or vomiting or heartburn
sensation.
Around 1 month prior to admission,
patient developed a new onset of passing out painless per-rectal bleeding in a
form of black-tarry stool. It was dark and mixed with his stools. He noticed
that his stool smells awfully disturbing and become stickier. The frequency of
bowel output however not changes as patient usually passes motion around once
in two days. After passing out the black-tarry stool, he experienced palpitation,
dizziness and syncope attack in which he needed to lie down to prevent from
fall. There is no episode of vomiting out blood, yellowish discoloration of the
eye and skin and no abdominal pain. He also denied any episodes of epistaxis,
bleeding gum or easily bruising. There was no associated tenesmus and passing
out mucus.
Since the beginning of the onset of
the per-rectal bleeding, he never went to seek for medical attention as he
claimed that in between the episode, he was feeling well. After one month, he
noticed he had weight loss by reduction in his pants size that is also
associated with loss in appetite. The amount of food intake has also reduced as
he felt easily full. This condition was also noticed by his daughter who
brought him to the hospital and during admission, several investigations had
been done to clarify the cause of his per-rectal bleeding.
SYSTEMIC
REVIEW
|
Respiratory system
|
There were no episodes of cough,
breathlessness or hemoptysis
|
|
Cardiovascular system
|
There was palpitation but no dyspnea,
orthopnea or chest pain
|
|
Hepatobiliary system
|
The patient has no jaundice
|
|
Hemopoietic system
|
This system was intact with no jaundice
or bleeding tendency
|
|
Neuromuscular system
|
This system was intact with no swelling
and weakness of muscles, bones and joints. There were also no abnormality of
movements and coordination.
|
|
Urologic system
|
Patient had episodes of gradually
increasing in difficulty of passing urine but with no episode of dysuria or
hematuria
|
PAST
MEDICAL HISTORY
He is a known case of diabetes
mellitus which is diagnosed 10 years ago. Currently he is on single type of
oral hypoglycaemic agent. Otherwise, he is not known to have hypertension,
ischemic heart disease or malignancy. There is also no history of blood
transfusion.
PAST
SURGICAL HISTORY
He has no previous history of
hospitalization. He also never underwent any form of surgical treatment or
intervention.
DRUGS
AND ALLERGY HISTORY
For the past 10 years, he had been
taking his oral hypoglycaemic agent regularly. For the past 1 year, he had been
taking commercial health supplement in a form of soluble powder that is taking
daily. Otherwise, there is no history of chronic ingestion of non-steroidal
anti-inflammatory drugs (NSAIDS) for any reason. He has no known allergies
towards drugs or foods.
FAMILY
HISTORY
His parents were passed away at the
age of 60 years old (both mother and mother) due to natural causes. He has two
siblings and he is the eldest.
There is no family history of
chronic disease such as diabetes mellitus, hypertension and ischemic heart
diseases running in the family. There is also no known family history of
gastrointestinal malignancy.
SOCIAL
HISTORY
He is a pensioner who previously
worked as an owner of a restaurant. Currently the restaurant is run by his son.
He lives in a single storey-house at Taman Haji Ahmad with his wife and his 4
children. He is a heavy smoker that smokes around 2 packs of cigarettes per
day. Otherwise, there is no history of chronic alcohol consumption, tattooing
or high risk behaviors.
PHYSICAL
EXAMINATION
GENERAL
Patient was lying comfortably in
supine position. He was alert, conscious and oriented to time, place and
person. He was not in pain or in respiratory distress. There was a peripheral
cannulation located at the dorsum of his right hand with no active infusion. He
looked pale but no jaundice noted. There was also wasting over the temporalis
muscle. The hydration status of the patient was however good.
VITAL
SIGNS
Blood pressure : 126/88
mmHg
Pulse rate : 88
beats/minute, good volume and regular rhythm
Temperature : 37 ˚C
Respiratory rate : 16
breaths/minute
HAND
His hand is dry, cold and pale.
There was also wasting of both thenar and hypothenar muscle. There was no
palmar erythema, clubbing, peripheral cyanosis, leukonychia and koilonychia.
There was no flapping tremor.
HEAD
There was pink conjunctiva and no
yellow discoloration on sclera.
The tongue was moist, no coated
tongue and it is pink in color. There was no central cyanosis, glossitis and
angular stomatitis.
LOWER
LIMB
There was no pitting oedema
ABDOMINAL
EXAMINATION
The abdomen was not distended.
There were no abnormal skin changes, scars or dilated veins. The cough impulse
was negative. The abdomen was soft and non-tender. There was a vague mass
located at the epigastric area that didn’t move with respiration. The mass was
not pulsating. The mass was hard and irregular margin. The surface was
unappreciable. There was dullness over the mass with percussion. Otherwise
there was no bruit heard over the mass. Otherwise there was no hepatomegaly and
splenomegaly. Both kidneys were not ballotable. There is negative shifting
dullness. The bowel sound was present. The left supraclavicular lymph node
(Virchow’s gland) was not palpable.
RESPIRATORY
EXAMINATION
The chest was normal in shape with
no scars of dilated veins. The chest expansion was equal bilaterally. There is
also equal vocal fremitus and both lungs field were resonance on percussion.
There is equal air entry with no added sounds was heard such as rhonchi or
crepitation.
CARDIOVASCULAR
EXAMINATION
The apex beat was palpable at left
5th intercostal space, midclavicular line. There are no thrills or
parasternal heave noted. Both normal heart sounds were heard with no murmurs.
NEUROLOGICAL
EXAMINATION
There was normal motor function of
both upper and lower limb with muscle power of 5 on all limbs. The sensory
parts were also normal with intact cranial nerve function.
SUMMARY
59 years old, Malay pensioner, a
heavy smoker, with underlying 10 years history of diabetes
mellitus currently on treatment,
presented with history of passing out black-tarry stool for 1 month, associated
with anaemic symptoms, loss of weight and loss of appetite, and epigastric
abdominal pain. There are no symptoms of metastasis. There is no family history
of malignancy. Physical examination revealed vague and hard epigastric mass
that is not moving with respiration.
PROVISIONAL
DIAGNOSIS
Carcinoma of the Stomach
Reasons favoring: First is his age
group. Incidence of carcinoma of the stomach peaks around the age of fifty to
seventy. He had central pain initially and become more localized to epigastric
pain, which is the characteristic of the pain change from colicky to burning
pain. The pain also exacerbated by eating. The pain was also not periodic, in
comparison to peptic ulcers. Loss of appetite and loss of weight is the
cardinal symptom of stomach cancer and usually occurs long before any other
symptoms arise. He also has symptoms of upper gastrointestinal bleeding which
is black tarry stool and symptoms of anemia. He is also a smoker which is one
of the risks to get stomach carcinoma. There is also vague mass palpable at the
epigastric region.
Reasons against: he has no symptoms
of intestinal obstruction, no altered bowel habit and he had a vague history of
gastric ulcer.
DIFFERENTIAL
DIAGNOSIS
1. Peptic Ulcer
Reasons favoring: Firstly is his age
group. Secondly, gastric ulcers usually cause loss of weight since patients are
afraid to eat and the pain is associated with food intake. Epigastric pain,
vomiting and water brash are also present in this patient, which are symptoms
favorable of a gastric ulcer. He is also anemic, that may suggest the complicat
ion of peptic ulcer which is bleeding and manifested by black tarry stool. He
is also a smoker which is one of the causes of peptic ulcer disease.
Reasons against: The patient did
not mention anything indicating a cyclic sort of pain, separated by a certain
period of time, which is a characteristic of a gastric ulcer. Duodenal ulcer
patient usually have a good appetite, and taking food relieves the pain. He
also had no history of NSAID usage, which is an important factor in the
elderly.
2. Esophageal varices
Reasons favoring: In the elderly;
one of the commonest causes of upper gastrointestinal bleeding is bleeding
esophageal varices.
Reasons against: Patient however
had no signs and symptoms suggestive of chronic liver disease, the condition
that is mostly associated with esophageal varices. He also is not known to have
risky behavior to develop chronic liver disease such as alcohol consumption and
history of hepatitis.
3. Chronic Pancreatitis
Reasons favoring: Epigastric pain
with significant weight loss.
Reasons against: The pain is
usually marked, and relieved by bending forward. There was also no steatorrhoea
or any indication of malabsorption.
4. Carcinoma of Pancreas
Reasons favoring: Firstly is his age
group which is more common at 50-70 years old. Patient also had symptoms of
chronic epigastric pain and constitutional symptoms. He is a smoker which is
one of the risk factors to get carcinoma of pancreas
Reasons against: The pain does not
associate with symptoms of obstructive jaundice, steatorrhea, diarrhea and
bloating.
INVESTIGATION
Blood
Investigation
1. Full blood count
Indication: since patient is
having per-rectal bleeding and clinically symptomatic
for anemia, full
blood count is taken to assess the severity of the anemia and at the same
time to assess the overall status of patient’s white cell
count for infection and platelet for
coagulopathy.
|
Parameters
|
|
|
(post
transfusion)
|
|
Hemoglobin
|
6.1
|
7.5
|
8.8
|
|
Total Red Cell
Count
|
2.25
|
2.90
|
3.54
|
|
PCV
|
20.3
|
25.6
|
27.1
|
|
MCv
|
90.2
|
88.3
|
87.7
|
|
MCH
|
27.1
|
25.9
|
27.5
|
|
MCHC
|
30.0
|
29.3
|
|
|
Total White Cell
Count
|
8.43
|
9.24
|
8.45
|
|
Platelet
|
337
|
322
|
337
|
Impression: patient is
severely anemic. Other parameters are normal.
2. Liver function test
Indication: with suspicious of
malignancy, the liver function is assessed to rule out
any liver
metastasis. LFT also is done to assess the nutritional status of the patient.
|
Parameters
|
|
|
Total bilirubin
|
3.6
|
|
Direct bilirubin
|
0.5
|
|
Indirect
bilirubin
|
3.1
|
|
Total protein
|
64.0
|
|
Albumin
|
32.0
|
|
Globulin
|
32.0
|
|
AG ratio
|
1.00
|
|
Alkaline
phosphatase
|
87
|
|
ALT
|
15
|
|
AST
|
22
|
Impression: with a normal
liver enzyme level, there is no parameter showing the
presence of liver
metastasis or liver involvement. The low protein and albumin level is
coinciding with
the patient history of significant weight loss, suggestive of impaired
nutritional
status.
3. Renal profile
Indications: renal profile can
be used also to assess the nutritional and hydrational
status of the
patient. Since patient also complaining symptoms of lower urinary tract
obstruction, renal
profile is used to assess the condition of the kidney.
|
Parameters
|
|
|
Urea
|
5.5
|
|
Sodium
|
140
|
|
Potassium
|
4.2
|
|
Chloride
|
110
|
|
Creatinine
|
115
|
Impression: raised creatinine
level in this patient may suggest an impending renal
injury, further
monitoring and investigation is needed. Raised creatinine may also due to
dehydration.
4. Coagulation Profile
Indication: to rule out
coagulopathy as the cause of the per-rectal bleeding.
|
Parameters
|
|
|
Prothrombin time
(PT)
|
13.8
|
|
PT ratio
|
1.1
|
|
INR
|
1.2
|
|
APTT
|
42.7
|
|
APTT ratio
|
1.1
|
Impression: all parameters are
normal.
5. Prostate Specific Antigen
Indication: to rule out the
presence of prostate carcinoma in view of
prostatomegaly and
obstructive symptoms of lower urinary tract.
|
Parameters
|
|
|
PSA
|
1.63
|
Impression: parameter is
normal.
Others
1. Oesophago-Gastro-Duodeno Scopy
(OGDS)
Indication: as a diagnostic
tool to confirm the presence of upper gastrointestinal
bleeding and to
confirm the cause. OGDS also can be used to get a sample of the mucosal
layer for
histopathological examination.
Impression: huge pre-pyloric
tumor extending into first part of duodenum with
ulcerated area
(Forest III). The tumor bleeds when biopsied. The pyloric ring was
deformed. The
esophagus and the second part of the duodenum were normal.
2. Histopathological Examination (HPE)
Indication: to confirm the
status of the tumor whether it is a malignancy or benign
lesion. Also to
assess the type of cell that made up the tumor.
Impression: poorly
differentiated adenocarcinoma
3. Electrocardiogram (ECG)
Indication: as a baseline
investigation and as a routine pre-operative
investigation.
Impression: normal ECG.
Imaging
1. Chest x-ray
Indication: to rule out the
presence of lung metastasis from the malignancy.
It is also as a
baseline investigation for pre-operative assessment.
Impression: there is no
cannon-ball opacity noted on the lung field that may
suggest presence
of metastasis.
2. Computed Tomography of
Thorax-Abdominal-Pelvis (CT TAP)
Indication: as a staging tool
of the tumor to look for local invasion, involvement of
regional lymph
nodes and presence of distant metastasis.
Impression: pre-pyloric tumor
with regional lymphadenopathy.
FINAL DIAGNOSIS
Pre-pyeloric
adenocarcinoma with symptomatic anemia
PRINCIPLE OF MANAGEMENT
1. Resuscitation
a. Set IV access
with 2 large bore peripheral cannula.
b. Draw out some
blood to send for laboratory investigation (FBC, LFT, Coagulation
profile, GSH)
c. If persistently
severe anemia, transfuse patient appropriately with blood product.
2. Prepare patient for surgical
intervention.
a. Radical therapy
i. Total gastrectomy
ii. Subtotal gastrectomy (Billroth II)
b. Palliative
therapy
i. Palliative bypass
ii. Stenting
3. Chemotherapy and radiotherapy
SUMMARY
OF PATIENT PROGRESSION
For the current admission, patient
is electively admitted for operative management. Patient
had undergone several
investigations and had been diagnosed as pre-pyloric adenocarcinoma of the
stomach. In the ward, blood investigation shows patient is severely anaemic.
Patients was then received 2 units of pack cell and the hemoglobin level raised
from 5 g/dl to 8 g/dl Patient had undergone palliative bypass surgery
(laparotomy with gastrojejunostomy and jejunojejunostomy). Post-operatively,
patient had no complications. Currently patient is still in the ward for
monitoring.
DISCUSSION
In Relation to
Disease
1) Epidemiology:
Patients with dyspeptic symptoms should
be investigated early rather than viewing the pain as a classical symptom of
gastritis. Those affected will firstly experience infection in the upper
gastrointestinal tract (oesophageal and stomach), but often only seek treatment
when the stomach cancer has developed to stage II or IV. According to studies,
82% of the patients presented with stage IV disease and curative surgery were
offered only to a 16% of them. Carcinoma of the stomach is the 10 most common
fatal cancers in Malaysia with about 1400 Malaysians developing it every year.
It can occur in adults of any age, however it is rare under the age of 50. It
is more common among men than women. Stomach cancer may affect males more
because they smoke and drink more than women. In Malaysia, stomach cancer is
the seventh most common cancer in males while it is the 10th most common cancer
in females. Its prevalence in terms of ethnicity shows the highest among the
Chinese (65 per cent).
2) Aetiology and
risk factors:
Until now, there are no definitive
aetiological agents have been recognized to cause gastric
cancer. There are several risk
factors that can be associated with the development of malignant change in the
stomach, i.e. the diet factor, H. pylori infection, benign gastric
ulcer, chronic atrophic gastritis, pernicious anaemia, and others.
Gastric cancer is noted more
commonly where malnutrition is prevalent. It also has been
associated with the use of certain
preservatives in food, nitrates, nitrites, and nitrosamines.
Recent epidemiological studies have
suggested that H. pylori may be associated with an
increased incident of malignant
change within the stomach. It may be due to its ability to produce ammonia and
other mutagenic chemical. Therefore, an investigation such as serology,
histology, or 13C tests should be
done to determine either the development of gastric carcinoma is also contributed
by H. pylori infection.
It is thought that chronic peptic
ulceration in stomach increase the risk of malignant change
within the ulcer. Same goes to
chronic atrophic gastritis (CAG) which is commonly associated with pernicious
anaemia (PA). Patients with these two conditions, CAG and PA have a fourfold increased
risk of getting stomach cancer compared to normal population.
3) Pathology:
Most of gastric cancers occur in
the antrum and almost invariably an adenocarcinoma. The
common type is intestinal and the
tumors are polyploidy or ulcerating lesions with heaped-up,
rolled-edges.
There are two classification of
gastric cancer, i.e. early and advanced gastric cancers. The
differences are stated in the table
as follow:
|
Early gastric
cancer
|
Advanced gastric
cancer
|
|
Confined to
mucosa and submucosa
|
Have penetrated
more deeply into the stomach wall
|
|
Minor
involvement of lymph nodes metastases
|
Lymphatic
metastases are frequently involved
|
|
No any other
signs of metastases to other organs
|
Associated with
a variety of distant metastases
|
4) Staging:
Staging in gastric cancer is done
by using the CT scan of the chest and abdomen to visua lize
the lungs, liver, peritoneal
cavity, and perigastric and retroperitoneal lymph nodes. It can also be done by
using ultrasonography which detects small metastases within the liver.
The staging is done by referring to
TNM classification as follows:
|
Staging
|
Prescription
|
|
T
|
|
|
1
|
Tumor extends to
lamina propria or submucosa
|
|
2
|
Tumor extends
into muscles
|
|
3
|
Tumor extends
into serosa
|
|
4
|
Tumor extends
into adjacent structure (bronchus, aorta)
|
|
|
|
|
N
|
|
|
0
|
No lymph nodes
involvement
|
|
1
|
< 7 nodes
|
|
2
|
7 – 15
|
|
3
|
> 15
|
|
|
|
|
M
|
|
|
0
|
No metastases
|
|
1
|
Metastases
|
5) Prognosis:
In general, the prognosis of
gastric cancer becomes worsened as it metastases to other
places. The table below shows the
examples of gastric cancer and their prognosis.
|
Stage
|
5-year survival
(%)
|
|
T1N0M0
|
95+
|
|
T1N1M0
|
70 – 80
|
|
T2N1M0
|
45 – 50
|
|
T3N2M0
|
15 – 25
|
|
M1
|
0 - 10
|
In Relation to
Patient
Mr. M, a 59 years old Malay, a
smoker, with underlying diabetes mellitus, was diagnosed with pre-pyloric
adenocarcinoma of the stomach. The patient which initially presented with
symptoms suggestive of peptic ulcer disease has been treated as outpatient and
was given medication with no investigations done for him. It has been proven
that gastric ulcer has the tendency to undergone malignant changes that can be
detected early if the ulcer is biopsied. In elderly, it is advisable for any
patient presented with gastrointestinal symptom, to be investigated properly to
rule out the presence of malignancy.
With no investigation done earlier,
patient eventually developed new-onset symptom of upper
gastrointestinal bleeding which is
passing out black-tarry stool but no hematemesis. At this point of disease
course, prompt investigation need to be done as patient already developed
symptomatic anemia. Endoscopic study (i.e. Oesophago-Gastro-Duodeno scopy) has
been chosen as the modality. OGDS which has been chosen as it has both
diagnostic and therapeutic value. Diagnostically, OGDS can be used to
demonstrate structural abnormalities of the gastric lumen. In this patient, it
has been found a presence of large tumor at the pre-pyloric area of the
stomach. At the same time of OGDS, tissue sample can be taken by the OGDS for
biopsy to rule out the presence of malignancy. The biopsied sample can further
be investigated for the presence of Helicobacter pylori which is found to cause
recurrence of ulcer in 50%. In this patient, histopathological examination of
the sampled tissue shows poorly differentiated adenocarcinoma which is the
commonest type of gastric malignancy.
To further stratify the patient
according to the severity of the disease, computed tomography
(CT) scan has been used to assess
the local infiltration of the malignancy to adjacent organ,
regional lymph nodes and to detect
the presence of distant metastasis to distant organ. In this
patient, there is regional
lymphadenopathy but no presence of distant metastasis.
As the final definitive management,
patient has been planned for surgical intervention. The
modality of choice can be divided
into curative surgery and palliative surgery. Curative surgeries which include
total gastrectomy or subtotal gastrectomy with regional lymph node resection requires
careful staging to ensure realistic chance of cure. While palliative surgery
involves the palliative bypass surgery or stenting. The surgical intervention of
choice will depend whether the tumor is resectable or not. In this patient,
initially he was planned for total gastrectomy with bypass surgery to be put in
stand-by. Intra-operatively however shows the tumor was not resectable, and in
this situation, palliative bypass surgery was the management of choice.
Stenting cannot be done for distal gastric tumor and was reserved for tumors
blocking the gastric inlet.
REFERENCES
1. Malaysian Oncology Society
2. Article: Gastric Cancer in
Malaysia, The Need for Early Diagnosis
3. Uptodate.com
4. Principles and Practice of
Surgery, 4th ed., O. James Garden, Andrew W. Bradbury, John
Forsythe, Churchill Livingstone,
2002.
5. Oxford Handbook of Clinical
Surgery, 3rd
Edition.
6. Oxford Handbook of Clinical
Medicine, 8th
Edition.
7. Kumar & Clarks’s Clinical
Medicine, 7th
Edition.
8. Essential Surgery; Problems,
Diagnosis and Management, 4th Edition.
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