clinicoclinico- pathologic · bleeding gastric ca --ulcerative type ... pneumonic process or...

ClinicoClinico--RadioRadio--

PathologicPathologicC O N F E R E N C E

17 Sept 200817 Sept 2008

Angelo King AuditoriumAngelo King AuditoriumCollege of Medicine, SLMCCollege of Medicine, SLMC

Anthony Uygongco MD, FPSGS, FPCS, FACSAnthony Uygongco MD, FPSGS, FPCS, FACS

DiscussantDiscussantDiscussantDiscussant

Chief complaint:Chief complaint:VomitingVomiting of bloodof blood

4444--year old maleyear old male

EsophagusEsophagus

EsophagealEsophageal varicesvarices

Esophageal caEsophageal caEsophageal caEsophageal ca

Reflux Reflux esophagitisesophagitis

MalloryMallory--WeissWeiss

StomachStomach

UlcerUlcer

VaricesVaricesVaricesVarices

Acute gastritisAcute gastritis

CarcinomaCarcinoma

Vascular Vascular ectasiasectasias

DuodenumDuodenum

UlcerUlcer

CarcinomaCarcinomaCarcinomaCarcinoma

HHistoryistory of of Present Present IIllnessllnessHHistoryistory of of Present Present IIllnessllness

RightRight flank painflank pain11

Month PTAMonth PTAIntermittentIntermittent

NonNon--radiatingradiating

Consult:Consult: ultrasoundultrasoundConsult:Consult: ultrasoundultrasoundNephrolithiasisNephrolithiasis, right, right

HepaticHepatic mass, leftmass, left

History of Present IllnessHistory of Present Illness

11Month PTAMonth PTA

Abdominal Abdominal CT scanCT scanConfirms ultrasound findingsConfirms ultrasound findings

Meds:Meds:TramadolTramadol//paracetamolparacetamolTramadolTramadol//paracetamolparacetamol

Lost to followLost to follow--upup


NeoplasticNeoplastic

Left Hepatic MassLeft Hepatic Mass

EsophagealEsophageal or or gastric gastric EsophagealEsophageal or or gastric gastric

varicealvariceal bleed ?bleed ?

Epigastric painEpigastric pain11

Week PTAWeek PTAModerate, Intermittent, burningModerate, Intermittent, burning

RelievedRelieved by food intakeby food intake

NauseaNausea

Self medications:Self medications:TramadolTramadol//paracetamolparacetamol

RanitidineRanitidine

No reliefNo reliefHistory of Present IllnessHistory of Present Illness

PepticPeptic ulcer diseaseulcer disease

Gastric or duodenal ulcer Gastric or duodenal ulcer ??

Left hepatic mass ?Left hepatic mass ?

Epigastric painEpigastric pain11

DayDay PTAPTAIncreasedIncreased in severity (VAS: 8/10)in severity (VAS: 8/10)

ContinuousContinuous

HematemesisHematemesis//melenamelenaHematemesisHematemesis//melenamelenaPallor,Pallor, weaknessweakness


Brought to local hospitalBrought to local hospital11

DayDay PTAPTA

Meds given:Meds given:Ranitidine, Ranitidine, Epinephrine, Epinephrine,

Tranexamic acidTranexamic acidTranexamic acidTranexamic acid

Temporary control of Temporary control of

bleedingbleeding


HematemesisHematemesis

FewFewHoursHours PTAPTA

Increased in frequencyIncreased in frequency

Severe Severe epigastricepigastric painpain

aandnd nauseanausea

Pallor,Pallor, weaknessweakness

Increased in frequencyIncreased in frequency

Every 2Every 2--3 hours, amount: ~ 1 cup3 hours, amount: ~ 1 cup

Transferred to SLMCTransferred to SLMC


UGIBUGIB

Gastric or duodenal ulcer Gastric or duodenal ulcer ??

Erosive gErosive gastritisastritis ??

VaricesVarices unlikelyunlikely

(+) Wt. loss:(+) Wt. loss: 30% in 2 yrs30% in 2 yrs

((--) Anorexia) Anorexia

((--) Fever) Fever

((--) Gum bleeding) Gum bleeding

((--) Cough) Cough

((--) ) HematuriaHematuria

ReviewReview ofof SystemsSystems

((--) Headache) Headache

((--) Night sweats) Night sweats

(+) Urinary frequency(+) Urinary frequency

(+) (+) DysuriaDysuria

PastPast Medical HistoryMedical History

NephrolithiasisNephrolithiasis, right, right-- Mar 08Mar 08Hepatic mass, leftHepatic mass, left-- Mar 08Mar 08

((--)) HypertensionHypertension

((--) Diabetes) Diabetes((--) Diabetes) Diabetes

((--) Hepatitis) Hepatitis

((--) Peptic ulcer disease) Peptic ulcer disease

((--) Allergies) Allergies

Personal Social Personal Social HistoryHistory

Seaman, presently a security guardSeaman, presently a security guardSmoker: 2 pack yearsSmoker: 2 pack years

(+) Financial difficulties(+) Financial difficulties

(+) Apprehensive of his condition(+) Apprehensive of his condition(+) Apprehensive of his condition(+) Apprehensive of his condition

Family HistoryFamily History

(+) Hypertension, CVA(+) Hypertension, CVA-- mothermother

Pertinent Physical ExamPertinent Physical Exam

Conscious, coherent, ambulatoryConscious, coherent, ambulatoryhyposthenichyposthenic,, in pain, not in CR distressin pain, not in CR distress

BP: 70/30 mmHgBP: 70/30 mmHgBP: 70/30 mmHgBP: 70/30 mmHg

HR: 91/minHR: 91/min

RR: 22/minRR: 22/min

Temp: 37.6Temp: 37.6°°CC

VAS: 8/10VAS: 8/10

Skin:Skin: GeneralizedGeneralized pallorpallor

HEENT:HEENT: Pale Pale palpebralpalpebral conjunctivaeconjunctivae

AnictericAnicteric scleraescleraeAnictericAnicteric scleraesclerae

Pupils 3mm equal, Pupils 3mm equal, briskybrisky

reacreactivetive to lightto light

No No tonsillopharyngealtonsillopharyngeal

congestioncongestion


Neck:Neck: SuppleSupple

((--) ) lymphadenopathieslymphadenopathies

Flat neck veinsFlat neck veins

No Carotid bruitNo Carotid bruit


Chest & lungs:Chest & lungs:

Symmetrical on expansionSymmetrical on expansion

clear breath soundsclear breath soundsclear breath soundsclear breath sounds

No retractions No retractions

No adventitious soundsNo adventitious sounds


Heart:Heart: AdynamicAdynamic precordiumprecordium

Apex beat at 5Apex beat at 5thth ICS LMCLICS LMCL

Normal rateNormal rate

Regular rhythmRegular rhythm

Distinct S1, S2 Distinct S1, S2

No murmursNo murmurs


Abdomen:Abdomen:

FlatFlat

NormoactiveNormoactive bowel sounds bowel sounds NormoactiveNormoactive bowel sounds bowel sounds

Soft, nonSoft, non--tendertender

(+) Palpable non(+) Palpable non--tender tender

epigastricepigastric mass, 4cm widest mass, 4cm widest

diameter, firm, smooth, fixeddiameter, firm, smooth, fixed


Abdomen:Abdomen:

Liver edge: sharp, palpableLiver edge: sharp, palpable at at

4 4 fingerbreathsfingerbreaths below the below the 4 4 fingerbreathsfingerbreaths below the below the

right right subcostalsubcostal angleangle

Spleen not palpableSpleen not palpable


Extremity:Extremity:

No gross dNo gross deformitieseformities

No edemaNo edemaNo edemaNo edema

No cyanosisNo cyanosis

No tremorsNo tremors

No atrophyNo atrophy

No decreased & unequal pulses No decreased & unequal pulses


Rectal:Rectal: Tight Tight sphinctericsphincteric tonetone

No palpable massesNo palpable masses

No No pararectalpararectal tendernesstenderness

No bloodNo blood

(+) Black stools on(+) Black stools on

examining fingerexamining finger


NeuroNeuro:: Conscious, coherentConscious, coherent

EuthymicEuthymic moodmood

intact recent, past &intact recent, past &

remote memoryremote memory

Intact EOM’sIntact EOM’s

(+) Corneal reflex(+) Corneal reflex

Intact V1, V2, V3Intact V1, V2, V3


NeuroNeuro:: Able to wrinkle foreheadAble to wrinkle forehead

smile and frownsmile and frown

(+) hearing on both ears(+) hearing on both ears

remote memoryremote memory

Intact gag reflexIntact gag reflex

Able to shrug shouldersAble to shrug shoulders

Tongue midline onTongue midline on

protrusionprotrusionPertinent Physical ExamPertinent Physical Exam

NeuroNeuro:: Sensory:Sensory: 100% 100% on all areason all areas

of the bodyof the body

Motor: strength 4/5 on allMotor: strength 4/5 on all

extremitiesextremities


Pertinent (+) PE findingsPertinent (+) PE findings

HyposthenicHyposthenic

HypotensiveHypotensive

PalePalePalePale

EpigastricEpigastric massmass

HepatomegalyHepatomegaly

MelenaMelena

Pertinent (Pertinent (--) PE findings) PE findings

((--) peritoneal signs) peritoneal signs

((--) signs of ) signs of cirrhosiscirrhosis

Salient featuresSalient features

4444 y/o male, y/o male, former former sseamaneaman

2 pack years smoking history2 pack years smoking history

Severe Severe epigastricepigastric pain, burningpain, burningSevere Severe epigastricepigastric pain, burningpain, burning

relieved by food intakerelieved by food intake

hematemesis & hematemesis & melenamelena


No acute wt. lossNo acute wt. loss

HypotensiveHypotensive

PalePale


Epigastric mass nonEpigastric mass non--tendertender

HepatomegalyHepatomegaly

((--) peritoneal signs) peritoneal signs((--) peritoneal signs) peritoneal signs

((--) signs of cirrhosis) signs of cirrhosis

Clinical ImpressionClinical Impression

Hypovolemic shock 2Hypovolemic shock 2°° to UGIB to UGIB

probably 2probably 2°° to Peptic Ulcer Diseaseto Peptic Ulcer Disease

Differential diagnosisDifferential diagnosis

1.1. Bleeding gastric vascular Bleeding gastric vascular ectasiaectasia

2.2. Bleeding gastric caBleeding gastric ca-- ulcerative typeulcerative type

3. 3. Bleeding Bleeding esophagogastricesophagogastric varicesvarices

22°° to liver neoplasm on a to liver neoplasm on a

background of cirrhosis background of cirrhosis

2.2. Bleeding gastric caBleeding gastric ca-- ulcerative typeulcerative type

Course in the WardCourse in the WardCourse in the WardCourse in the Ward

IVIV resuscitationresuscitationadmadm

DayDay

Meds:Meds:

Blood transfusionBlood transfusion1 u PRBC, 1 u FWB1 u PRBC, 1 u FWB

Meds:Meds:Tranexamic acidTranexamic acid

EsomeprazoleEsomeprazole IVIV

SomatostatinSomatostatin dripdrip

IVIV VitVit. K. K

Course in the WardCourse in the Ward

admadmDayDay

Stat UGI endoscopyStat UGI endoscopyBloodBlood clots occupying the stomach clots occupying the stomach

and the duodenumand the duodenum

No signs of active bleedingNo signs of active bleedingNo signs of active bleedingNo signs of active bleeding

CBCCBCN 86N 86

L 7.0L 7.0

6. 96. 9

20.820.838638616.6916.69


BUNBUN 84.084.0 77--21 mg/dl21 mg/dl

CreaCrea 4.834.83 0.80.8--1.51.5 mg/dlmg/dl

AlbuminAlbumin 2.52.5 3.43.4--5.0 g/dl5.0 g/dl

GlobulinGlobulin 5.15.1 2.32.3--3.5 g/dl3.5 g/dl

AlkAlk. . PhosPhos 360360 5050--136 u/L136 u/L

Direct Direct BiliBili 0.60.6 00--0.3 mg/dl0.3 mg/dl

SGPTSGPT 83.083.0 1111--66 u/L66 u/L

Direct Direct BiliBili 0.60.6 00--0.3 mg/dl0.3 mg/dl

Indirect Indirect BiliBili 0.80.8 00--0.8 mg/dl0.8 mg/dl

Total Total BiliBili 1.41.4 00--1.01.0

ProtimeProtime 14.4” (66%)14.4” (66%)

Course in the WardCourse in the Ward**

admadmDayDay

Chest xChest x--ray:ray:Multiple pulmonary nodules:Multiple pulmonary nodules:

Pneumonic process or pulmonary Pneumonic process or pulmonary

metastasismetastasis

Admitted to ICUAdmitted to ICU

metastasismetastasis


(+) NGT(+) NGT bleed: 130ml/24 hrsbleed: 130ml/24 hrs22ndnd

HospitalHospital

DayDay

Epigastric painEpigastric pain

Blood transfusionBlood transfusion1 u PRBC, 1 u FWB1 u PRBC, 1 u FWB1 u PRBC, 1 u FWB1 u PRBC, 1 u FWB

VITAL SIGNS:VITAL SIGNS:

BP: 120/75 BP: 120/75 -- 130/80130/80

HR: 80HR: 80--90 90

N 87N 87

L 6.0L 6.0

10.210.2

30.730.724024024.724.7


Na+ Na+ 133133 135135--145 145 mmolmmol/L/L

K+K+ 3.53.5 3.63.6--5.5 5.5 mmolmmol/L/L

ClCl-- 103103 9898--107 107 mmolmmol/L/L


ClCl-- 103103 9898--107 107 mmolmmol/L/L

44thth

HospitalHospital

DayDay

Repeat Repeat UGI endoscopyUGI endoscopyWhite based ulcer ~White based ulcer ~ 5mm at 5mm at

stomach corpusstomach corpus

No signs of recent bleedingNo signs of recent bleedingNo signs of recent bleedingNo signs of recent bleeding

(+) opening (+) opening at at anterior wall of anterior wall of

duodenal bulbduodenal bulb with ulcerating with ulcerating

bordersborders ,, tubular in structure, tubular in structure,

margins irregular and raw area at margins irregular and raw area at

its baseits base..

D2 unremarkable D2 unremarkable


44thth

HospitalHospital

DayDay

CT scan abdomenCT scan abdomenHeterogenouslyHeterogenously calcified left calcified left

hepatic masshepatic mass


ClinicalClinical--endoscopicendoscopic--radiologic findings:radiologic findings:

Esophagus:Esophagus:NoNo varicesvarices notednoted

NoNo lesions notedlesions noted

StomachStomachGastric ulcer corpus no signs of recent bleedGastric ulcer corpus no signs of recent bleed

ErosiveErosive gastritisgastritis

No No intraluminalintraluminal massmass

No No submucosalsubmucosal massmass

ClinicalClinical--endoscopicendoscopic--radiologic findings:radiologic findings:

Duodenum:Duodenum:Consideration before CT scanConsideration before CT scan

> > DiverticulumDiverticulum,, Fistula,Fistula, SSealedealed perforationperforation

Consideration AfterConsideration After CT scanCT scan

> Fistula> Fistula

UnremarkableUnremarkable D2D2

Duodenum D1Duodenum D1

Liver massLiver mass

Abdominal CT findings of Abdominal CT findings of heterogenouslyheterogenously

calcified left hepatic mascalcified left hepatic mass s

and and pneumobiliapneumobilia

Considerations:Considerations:

1. Inflammatory1. InflammatoryTuberculosisTuberculosis

Chronic amoebic abscessChronic amoebic abscess

2. Parasitic2. ParasiticEchinococcosEchinococcos cystcystEchinococcosEchinococcos cystcyst

33. . NeoplasticNeoplasticPrimaryPrimary-- HCC, ICACHCC, ICAC

MetastaticMetastatic

DiagnosisDiagnosis

1. Hypovolemic shock sec. to UGIB 1. Hypovolemic shock sec. to UGIB

probably sec. to acute erosive gastritis probably sec. to acute erosive gastritis

2. Hepatoduodenal fistula probably sec. to 2. Hepatoduodenal fistula probably sec. to

> hepatic TB> hepatic TB

> hepatic Ca> hepatic Ca

66thth

HospitalHospital

DayDay

Severe Severe epigastricepigastric painpainHematemesisHematemesis

VITAL SIGNS:VITAL SIGNS:

BP: 90/60 BP: 90/60 -- 100/70100/70BP: 90/60 BP: 90/60 -- 100/70100/70

HR: 80HR: 80--90 90

Meds:Meds: SomatostatinSomatostatin dripdrip

Blood transfusionBlood transfusion1 u PRBC, 1 u FWB1 u PRBC, 1 u FWB


66thth

HospitalHospital

DayDay

Hematemesis persistedHematemesis persisted

100ml/24 hrs100ml/24 hrs

Exploratory Exploratory laparotomylaparotomy88thth

HospitalHospital

DayDay


Thank you.Anthony Uygongco MD, FPSGS, FPCS, FACS

clinicoclinico- pathologic · bleeding gastric ca --ulcerative type ... pneumonic process or...

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