A case of epigastric mass
-clinical case presentation
Dr. Karthikeyan, Dr. Madhan, Dr. Pradeep
Post graduate residents
Department of General Surgery
Chief complaints
• A 68 years old male Mr. X, residing in Thiruvannamalai, farmer by
occupation, belongs to lower socio-economic status came with chief
complaints of
• Upper abdominal pain for last 6 month
History of presenting illness
• Patient was apparently asymptomatic 6 months back, then he
developed upper abdominal pain which was insidious in onset, static
in nature. Constant dull aching type of pain, not radiating without
any periodicity with specific aggravation during food intake and no
specific relieving factors.
• Associated with loss of appetite, Early satiety and significant
unintentional loss of weight for last 6 months(60kg to 50kg in last
6months).
• History of black, tarry, sticky to pan stools for last 2 months
• History of easy fatiguability for last 2 months
History of presenting illness(Cont.)
• No history of nausea or vomiting
• No history of abdominal distension
• No history of ball rolling movements
• No history of difficulty in swallowing or heart burn or chest pain
• No history of jaundice
• No history of breathlessness / cough with expectoration
• No history of fever
• No history of any swelling in the body
Past History
• Patient had past history of upper abdominal pain on and off for 5-6 years.
Associated with food intake (aggravates with food). Associated with in
between period of remission for almost 3 to 4 months. Each relapsing event
last for around 1-2 months. The relapse usually follows continuous spicy food
intake. He used to take over the counter medications for abdominal pain.
(mostly took antacid syrup formulations).
• Last episode was 1 year back and lasted for 1 month. He was asymptomatic
for a period of 5 months before the onset of presenting complaints.
• 3 months back for the presenting complaints he visited a hospital, where he
was advised to undergo UGI scopy. (no documents of consultation is
available)
Past History (cont.)
• Not a known case of Systemic HTN, DM, BA, COPD, Epilepsy,
Thyroid disorder, CAD.
• No History of previous surgery
• No history of previous hospitalization/ blood transfusion
Personal history
• Diet:
• Non-vegetarian, consumes mixed diet
• Consumes spicy and pickled items regularly
• Consumes balanced meal with vegetables
• Consumes fruits once or twice in a week (mostly citrus fruits)
• Bowel & bladder: unaltered
• Sleep: unaltered
Personal history (cont.)
• Chronic smoker, 8 to 10/ day for last 25 years
• Alcoholic for 25 years, consumes 2-3 days in a week (100-180ml of
brandy per day)
• No history of betel nut chewing
Family history
• No known history of cancer in his family
Treatment history
• For the presenting complaints, he took over the counter medication 3
month back, as he was not relieved of pain, he consulted a doctor,
there he was advised for UGI scopy. But patient refused. (no
documentation of consultation available)
• Not on any chronic medication
• No History of drug allergy
• No history of previous hospitalisation
Summary
• A 68 years old male belongs to lower socio-economic status without any
co-morbidities, without any family history of malignancy, who is a
chronic smoker and alcoholic for 25 years, with long term past history
of Upper abdomen pain with periodicity (remission period in-between)
now presented with constant dull aching upper abdominal pain,
significant unintentional weight loss and loss of appetite for 6 months.
He also had melena and easy fatiguability for last 2 months. Without
any history suggestive of GOO or Metastasis
GENERAL EXAMINATION
After obtaining verbal consent, patient was examined in a well lit room
and privacy ensured.
Patient was conscious, oriented to time,place and person.
afebrile
Hydration - fair
Moderately built and moderately nourished
Pallor present, Pitting pedal edema present
No icterus/ cyanosis/ clubbing/ generalized lymphadenopathy
GENERAL EXAMINATION
VITALS:
BP - 100/70 mm Hg in right upper arm in sitting position
PR - 80/ min normal volume, regular rhythm
EXAMINATION OF THE ABDOMEN
INSPECTION:
• Abdomen flat except in the epigastric region.
• Fullness noted in the epigastric region.
• All quadrants moves equally with respiration.
• Umbilicus in midline and inverted.
• Skin over the abdomen normal - no scars / no sinuses / no dilated
veins.
• no visible peristalisis
• B/L Hernial orifices free.
• B/L flanks free.
• No supraclavicular fullness.
• No left axillary fullness.
• External Genitalia Normal
PALPATION
• A mass of size 6 x 5 cms noted in the epigastric region, no warmth,
tenderness present, no guarding / rigidity
Superior border - 4 cm below the xiphisternum
Inferior border - 5 cm above the umbilicus
Right side border - 2 cm from the midline
Left side border - 3 cm from the midline
• Irregular in shape
• Surface irregular
• Margins well defined
• Firm to hard in consistency
• moves with respiration
• Plane of the Swelling - Intra abdominal, Intraperitoneal
• Liver not palpable
• No other organomegaly
• Supraclavicular fossa free
• B/L Hernial orifices free
• B/L flanks free
• External genitalia normal
PERCUSSION
• Impaired resonance over the mass
• No free fluid in the abdomen
AUSCULTATION
• Normal bowel sounds heard
• No bruit heard over the swelling
PER RECTAL EXAMINATION
• Normal sphincter tone
• no mass / nodule felt
• Blackish fecal staining present
OTHER SYSTEM EXAMINATION
• CVS - S1 S2 +, no murmur
• RS - Bilateral air entry present + , no added sounds
• CNS - No focal neurological deficit
SUMMARY
68 year old male, belonging to lower socio economic status with no
comorbidities, who is chronic smoker and alcoholic presented with
upper abdominal pain, early satiety, malena and significant weight loss.
On examination he was plae, with an intraabdominal, intraperitoneal
epigastric mass which moves with respiration, with no VGP/VIP, no
palpable Left supraclavicular node, no blumer's shelf with blackish
stools on digital rectal examination.
A case of epigastric mass probably due to Carcinoma Stomach, most
probably arising from body of stomach.
