Download MBBS Final Year Surgery Case Presentation Carcinoma Stomach Clinical Examination Discussion and Treatment

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Name: Mr.Rajendran

Sex: Male

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Age: 62 years

Occupation: watchman

Socio economic status: lower middle

CHIEF COMPLAINTS

• Loss of weight and loss of appetite for 5 months

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• Vomiting for 4 months

HISTORY OF PRESENTING ILLNESS

• The patient was apparently normal 5 months back after which he developed loss of weight and appetite- 5 months (6kgs)
• H/o vomiting for past 4 months, insidious onset, 1-3 episodes/day.
• Contains food particles, not bile stained, after 1-1.5hrs of consuming food, not projectile, not relieved by medications.

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• H/o passage of black stools, tarry, sticky, foul smelling stools for 1 month, 1-2 episodes/day
• H/o nausea
• No H/o hematemesis
• H/o ball rolling movements present
• H/o early satiety

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• No H/o difficulty in swallowing
• No H/o abdominal pain/distension/belching
• No H/o heartburn
• No H/o abdominal mass
• No H/o indigestion and epigastric discomfort

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• No H/o constipation and obstipation
• No H/o fever
• No H/o suggestive of chronic gastritis
• No H/o bone pain, breathlessness, chest pain, hemoptysis
• No H/o swelling elsewhere in the body

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PAST HISTORY

• No H/o similar complaints in past
• No H/o previous hospitalization/ surgery
• No H/o DM,TB, HT, asthma, epilepsy, typhoid, jaundice.
• No H/o chronic drug intake

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• No H/o radiation exposure

PERSONAL HISTORY

• Consumes non vegetarian diet
• Normal bowel and bladder habits
• No addictive habits

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• No H/o excessive consumption of coffee
• No H/o consumption of high salt and high calorie food
• No H/o excessive consumption of spicy foods
• No H/o excessive consumption of preserved foods
• No H/o drug/food allergy

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FAMILY HISTORY

• No relevant family history.

GENERAL EXAMINATION

• Patient is conscious, oriented, moderately built and nourished, hydrated.
• Pallor present

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• No icterus/ cyanosis/clubbing/pedal edema/generalised lymphadenopathy

ORAL HYGIENE

• Poor
• Dental caries present

HEAD TO FOOT EXAMINATION

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• No acanthosis nigricans
• No irish nodes in the axilla
• No seborrheic dermatitis
• No markers of liver cell failure.

VITALS

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• Pulse rate; 80/min, regular in rhythm, normal volume and character, no vessel wall thickening, no radioradial/ radiofemoral delay, felt in all peripheral vessels
• Blood pressure; 110/70 mm Hg measured in right upper arm in sitting posture
• Respiratory rate: 17 per minute, abdominothoracic
• Temperature: afebrile

EXAMINATION OF ABDOMEN

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After getting consent and explaining the procedure, the patient is exposed from mid chest to mid thigh and examined under bright light in supine position

INSPECTION

• Abdomen: epigastric fullness seen, flanks free, umblicus in midline, everted, no visible nodules in periumblical region
• All quadrants move equally with respiration
• Visible gastric peristalsis seen

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• No visible mass/ pulsation
• No scar, sinuses, dilated veins
• No divarication of recti, external genitalia normal
• Hernial orifices free
• Supraclavicular fossa : no visible fullness

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PALPATION

• Not warm, not tender
• A single mass 5*5 cm felt in epigastric region extending 6cm below xiphisternum, 3cm above umblicus, 3cm from midline towards left side and 2cm from midline towards right side
• Surface: irregular, well defined margins, hard in consistency, not mobile, moves with respiration
• Rising test: swelling becomes less prominent

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• Lateral recumbent position: becomes more prominent
• Plane of swelling: intra abdominal
• Succussion splash present
• No pulastion felt over mass
• No cough impluse

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• No organomegaly
• External genitalia normal
• Left supraclavicular node – not palpable (TROISIERS SIGN negative)
• Axillary lymph nodes not palpable
• Para-aortic nodes not palpable

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• Inguinal nodes not palpable

MEASUREMENTS

• Xiphisternum to umblicus-14 cm
• Umblicus to pubic symphysis-12 cm
• Spino umblical line-14cm on both sides

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• Abdominal grith-74 cm

• PERCUSSION: no free fluid, impaired resonance over mass
• AUSCULTATION: normal bowel sounds heard, no arterial bruit/ venous hum
• AUSCULTOSERAPING :impaired resonance
• PER RECTAL EXAMINATION: to be done

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SYSTEMIC EXAMINATION

• RESPIRATORY SYSTEM: normal vesicular breath sounds heard and no added sounds
• CARDIOVASCULAR SYSTEM: S1 S2 heard and no murmurs
• CENTRAL NERVOUS SYSTEM: no focal neurological defect
• Spine and Cranium : Normal

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DIAGNOSIS:

• Carcinoma stomach involving distal part of stomach with symptoms of gastric outlet obstruction

INVESTIGATIONS

• BASELINE:
  • CBC, TC, DC, Hb%, ESR
  • Urine – sugar, albumin

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  • Blood- sugar, urea, creatinine
  • Blood grouping(A) and typing
  • Chest X-ray
  • ECG
  • Liver function test

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  • Renal function test

SPECIFIC:

• USG abdomen
• Upper GI endoscopy(flexible)& biopsy

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• Barium meal
• Contrast enhanced CT abdomen
• Endoscopic ultrasonography
• Diagnostic laproscopy
• CT chest

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• Liver function test
• PET scan
• Tumour marker-CA724
• Skeletal survey

TREATMENT :

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• Lower radical (subtotal) gatrectomy with billroth II (roux-en-y) gastro jejunostomy