INTRODUCTION

Name : D M A

Age : 59 years old

Gender : Male

Race : Malay

Occupation : Pensioner

Address : Taman Haji Ahmad 3, Kuantan, Pahang.

Date of admission : 23th March 2015

Date of Clerking : 26th March 2015

HISTORY

CHIEF COMPLAINT

Patient presented with 5 months history of progressive abdominal pain associated with per

rectal bleeding and early satiety for 1 month duration.

HISTORY OF CHIEF COMPLAINT

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, water brash 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 however episode of vomiting out

blood, yellowish discoloration of the eye and skin, and no right hypochondriac 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 per-rectal bleeding, he was feeling well. Until after a

month of the onset of per-rectal bleeding that he noticed that he had some weight loss by the

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

Skin Skin was normal with no change in the color and contour. There was

also no itchiness noted.

Head There were no swellings or any injury of the face.

Eyes There was pallor, but no jaundice, no redness or any discharge from the

eyes.

Ears There was no discharge or hearing impairment.

Nose There was no discharged, nose block, bleeding or odor from the nose.

Mouth and

throat

There was no any odor.

Neck The neck region was normal. There were no any swellings or stiffness.

Respiratory

system

There were no episodes of cough, breathlessness, noisy breathing or

hemoptysis

Cardiovascular

system

There was palpitation, but no dyspnea, orthopnea, cyanosis, or chest

pain.

Hepatobiliary

system

The patient has no jaundice.

Hemopoietic

system

This system was intact with no jaundice or bleeding tendency

Neuromuscula

r 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 hypoglycemic 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.

DRUG AND ALLERGY HISTORY

For the past 10 years, he had been taking his oral hypoglycemic 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

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. There was also evidence

of impaired nutritional status from wasting of both thenar and hypothenar muscle. The hydration

status of the patient was however good.

There were no stigmata of liver disease noted such as flapping tremors, loss of axillary hair

and spider nevi. There were also no bruises over the upper and lower limb. There was no

injection marks and tattoo noted. There was also no pedal edema.

VITAL SIGNS

Blood pressure : 126/88 mmHg

Pulse rate : 88 beats/ minute, good volume and regular rhythm

Temperature : 37oC

Respiratory rate : 16 breathe/ minute

PERABDOMINAL 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 with irregular margin. The surface was unappreciable. There

was dullness over the mass with percussion, Succussion splash test was negative. 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.

DIGITAL RECTAL EXAMINATION

On inspection, there was no skin rashes, excoriation, mass, scars, fistula or fissures.

However, a small skin tag was seen at 6 o’clock position. There was no fecal soiling, blood or

mucus discharge.

Upon digitation, the tone of the sphincter was present and normal. Prostate gland was

enlarged but symmetrical. The surface is smooth and firm to consistency. The median sulcus was

palpable. Otherwise the rectum was empty with no masses felt. Upon removal the finger, there

was dark brownish feculent stain over the finger.

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 anemic 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 complication 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-pyloric 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 severley anemic. 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:

According to Dr Ramesh Gurunathan during Third Asia Pacific Gastroesophaegeal Cancer

Congress held at Sunway Medical Centre, Selangor, he said that 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 submucosaHave penetrated more deeply into the

stomach wall

Minor involvement of lymph nodes

metastasesLymphatic 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

visualize 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 Description

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 < 7nodes

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.