Name: Kashara Sabastian

Age: 58

Sex: Male

Address: Biyanaguru

Tribe: Mnyankole

Religion: Catholic

DOA: 10th oct 2010

Presenting Complaint

Abdominal pain on and off for 2 months

History of Presenting Complaint

Kashare was relatively well until two months ago when he noticed an episode of abdominal pain.
Which started gradually and was on and off since October,The pain was localized in the epigastric
region and was burning in nature. It was aggravated by eating food and was relieved sometimes by
vomiting, the pain didnot radiate to any other part. The patient reported he had lost appetite for food
because the food worsened his pain and also caused him to vomit in two to three hours after
eating, the vomitus he reported, contained some undigested food and was yellow in colour, the
patient reported he had never vomited blood or blood stained vomitus. The pain was not associated
with fever nausea or vomiting but reports he had been experiencing weight loss of late. He also
reported of early satisfaction whenever he takes meal however there was no history of heart burn
dysphagia or odynophagia. no history of yellowing of eyes and change in stool color eventhough he
had been constipated for the last three days, No history of trauma. He also says that he hadn’t
experienced any change in his urine color, smell, frequency, or pain when urinating. Kashare
admits that he drank alcohol and smoked cigarette for about 12 years but had quit them both about 4
months ago.

Systemic Review

Respiratory- No history of cough, shortness of breath, or chest pain.

Cardiovascular- No palpitation, leg edema, syncope, or easy fatigability.

Nervous System- No headache, dizziness, visual or hearing problem, limb weakness or loss of
sensation.

Muskuloskeletal- No joint pain, joint stiffness, or dry eyes.

Past Medical History

HIV serostatus not known, no history chronic illnesses. No food or drug allergy.
Past Surgical History

Had two previous abdominal operations one in 1999 in Kyomuhunga and the other one in june 2010
at KIUTH.

Family History

He is the 2nd born of a family of 8. 2 of his siblings died for a disease unknown to him. Both parents
died as well. He remembers that his mother used to complain about her stomach but not sure
whether it was the reason of her demise. No familial disease in the family.

Social History

He is a peasant farmer in Monogamous Relationship with 8 children. All alive and well. There is
long standing history of alcohol consumption and smoking.

Summary

58 year old male who presented with epigastric pain associated with loss of appetite massive
weight loss early satiety and vomiting following meals , no history of heart burn dysphagia
hematamesis or hematochezia. The pain is aggravated by food and relieved by vomiting. No history
of pain radiation or constitutional symptoms such as fever.

General Exam

He is sick-looking elderly man who is severely wasted. Had mild conjuctival pallor, and had
enlarged submental and submandibular lymph nodes. Had no jaundice, finger clubbing, oral thrush,
or edema. afebrile on touch with an axillary temperature is 37.3c.

Respiration Exam

The RR was 20bpm (normal). Chest was moving symmetrically with respiration. Trachea was
centrally placed. Chest was non tender and chest expansion was normal. Vesicular sounds were
heard in all lung fields.

Cardiovascular Exam

Pulse- 95bpm normal volume, regular and synchrous with other pulses. BP - 110/75 (normal). JVP
was not raised. Apex beat was palpable at the left 5 th ICS mid clavicular line. Heart sounds 1 and 2
were heard. No murmur or gallop.

Abdominal Exam

Appears slightly scaphoid and symmetrical. It’s moving with respiration. There is scar from past
abdominal operation. No obvious masses. No colour change around the umbilicus or flanks.
Tenderness could be elicited on deep palpation and was significant in the epigastric, and left
hypochondrium. No masses or enlarged organs were palpated. No renal angle tenderness. The
percussion note was normal. No shifting dullness. Bowel sounds were heard and were normal. PR
was not done.

CENTRAL NERVOUS SYSTEM

Impression:

Gastric carcinoma

Differential Diagnosis

Gastritic ulcer

Gastric outlet obstruction

Small Bowel Obstruction

NB: the patient escaped from the ward.

Discussion:

Gastric carcinoma is a malignant condition affecting the stomach and carrying poor prognosis
because most of the times the condition maniftests in late stage. It affects males more than women
by a ratio of 2:1 and is commoner after the age of 40. Carcinomas arising in the lower third of the
stomach are common in low socioeconomic societies while those occurring in the upper third of the
stomach is common in high socioeconomic classes like people in the western world. The
predisposing factors of cancer of the stomach include among other things:

1.H.pylori infection

2.Gasctic ulcers

3.Chronic gastritis-atrophic or pernicious anemia

4.Gastric adenomas

5.Cigarete smoking and alcohol consumption

6.Nitrosamines in the preservation of foods

8.Partial gastrectomy-bilous reflux

9.Barrets esophagus

10.Radiation therapy

11. Genetic factors

History

Most gastric cancers present at an advanced stage. The presentations equally non-specific -5A’s

(Asthenia, abdominal pain, Anorexia,Anaemia Achlorhydria)

1.Weight loss (asthenia) most common symptom

2. Abdominal pain .This may be epigastric, substernal, or back. Abdominal pain may mimic that of
benign peptic ulcer disease, with relief of pain obtained by ingesting antacids, H 2-blockers, and
food. In other patients, pain is worse after eating

3. Anorexia and vomiting are present, especially if distal tumors cause pyloric obstruction.

There is also associated dyspepsia and early satiety.

4. Constipation- Because of reduced dietary intake, this is common.

5. Both acute and chronic upper gastrointestinal bleeding may occur, with hematemesis and melena,
though frank hemorrhage occurs infrequently, usually in less than 10% of patients.

6. Anemia- Weakness and fatigue related to anemia and also due to weight loss due to decreased
dietary intake.

Worsening angina pectoris and dyspnea may be related to progressive anemia.

1.Gastroscopy, biopsy, and cytology-Gold standard

2.Barium meal –double contrast(with Air)

In absence of an upper GI endoscopy, this can be done. Some of the abnormalities noted include

-Lack of distensibility of the stomach

-An ulcerated mass or mass effect surrounding an ulcer

-A mass in any portion of the stomach

-Enlarged gastric folds

3.Endoscopic ultrasonography

Staging of gastric cancer TNM

TX.TO,TIS
T1 tumors invade to the submucosa

T2 invade the muscularis propria

T3 penetrate the serosa/adventitia

T4 invade adjacent structures.

Nodes

N1 if there are metastases to peri gastric nodes

N2 if regional lymph nodes are involved

N3-IVC and Aorta nodes

MX-Metastasis can’t be assessed.

M1-Presense of metastasis

MANAGEMENT

Surgery

Gastrectomy

1. Billroth II -Resection of the distal stomach, closing the transected duodenum and stomach and
restoring continuity by a gastrojejustomy to the posterior wall of the stomach-

Total gastrectomy

-Proximal tumours-cardia and fundal tumours necessitates

total gastrectomy.

-This carries a lower risk of recurrence or a second gastric cancer in long-term survivors.

-Total gastrectomy with a Roux-en-Y esophago-jejunostomy to prevent alkaline reflux.

-The preferred method of reconstruction after total gastrectomy is as a Roux-en-Y with a 60-cm
Roux to prevent bile reflux.

-Gastric cancer at the cardia the tumour may infiltrate the lower oesophagus, and a 10-cm
oesophageal clearance is advised to be certain of clear resection margins.

-Thus surgery involves principles of gastric as well as oesophageal surgery, and in certain respects
it should be regarded as a separate entity.

References:
Bailey and love’s short practice of surgery

www.wikipedia.org