Download MBBS Final Year Surgery Case Presentation Gastric outlet Obstruction Clinical Examination Discussion and Treatment

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Chief Complaints

• Mr.Durai, 48 yrs male from Coimbatore, who is an electrician by occupation and belongs to Lower socioeconomic class presented with chief complaints of
• Vomiting – for 3 months

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• Mass in the upper abdomen – for 3 months

History Of Presenting illness

The patient was apparently normal before 3 months after which he developed vomiting for 3 months

• insidious in onset, non bilious, not blood stained,contains food particles
  • 1-3 episodes per day
• Immediately after food intake (within 20 minutes)

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• Not relieved by medication
• Not projectile, non progressive

The patient also noticed a mass in the upper abdomen

• Insidious in onset
• Gradually progressive in nature

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• Associated with pain on pressing
• H/O constipation, no h/o obstipation
• H/O dyspepsia, no h/o belching
• No h/o halitosis
• H/O ball rolling movements present

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• H/O loss of weight (7kg in 3 months) and loss of appetite

• No h/o dysphagia
• No h/o Black tarry stools
• No h/o black tarry stools
• No h/o fever

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• No h/o yellowish discolouration of sclera / abdominal distention
• No h/o bone pain
• No h/o cough with haemoptysis
• No h/o swelling elsewhere in the body

Past History

• No h/o similar complaints in the past

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• No h/o previous surgeries
• No h/o chronic drug intake
• No h/o DM, HT, Tuberculosis, Asthma, Epilepsy

Personal History

• Consumes non vegetarian diet
• Chronic alcoholic for past 20 years – 180 ml/day

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• Occasional smoker
• No h/o spicy food intake
• Normal bladder habits. Constipation is present

Family History

• No significant family history

Summary

• 48 years old male, who is a chronic alcoholic came with complaints of non-bilious vomiting- immediately following food and water intake, mass in the epigastrium for 3 months with history of constipation, ball rolling movements and loss of weight and loss of apetite. Probable pathology is in the gastric region.

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General Examination

Patient is conscious, oriented, moderately built and moderately nourished.

• Pallor present, No cyanosis, No jaundice
• Grade 2 clubbing present
• No pedal edema
• No generalized lymphadenopathy

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VITAL SIGNS

• Pulse Rate 75/ min, regular in rate, rhythm.No specific character. No vessel wall thickening. No radioradial/radiofemoral delay.
• BP: 116/80 mmHg, measured in the right upper arm seated posture
• RR 15/min
• Temp afebrile

Examination of Abdomen

After getting consent from the patient, he was exposed from the level of the nipples to midthigh and examined under bright light in supine position.

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INSPECTION

• A single, locally distended mass is present in the epigastric region. Size: 7x5 cm, irregular in shape, extending 2cm below the xiphoid process, 2cm from the left costal margin, 6 cm from the right costal margin and 5cm above the umbilicus. Moves with respiration

• Skin over the mass – normal
• On lifting the head with arms folded on chest, mass becomes less prominent
• Visible Gastric Peristalsis
• Umbilicus in midline, flanks free

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• All quadrants move equally with respiration
• No fullness in the left supraclavicular fossa
• External genitalia normal

Palpation

• The patient's hips and knees are flexed on both sides and examination is done.
• Inspectory findings of size, shape, extent confirmed.

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• Surface irregular, Ill defined margins
• Moves with respiration
• Left Supraclavicular node and axillary nodes not palpable
• Liver not palpable

Percussion:

• Shifting dullness is absent

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• Liver dullness Right 5th Intercostal Space in the Mid Clavicular line
• Impaired resonance over the mass.
• Resonant over other regions of the abdomen

Auscultation:

• Normal Bowel sounds heard.

Per Rectal Examination

Diagnosis

• Gastric Carcinoma with Gastric Outlet Obstruction

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Differential Diagnosis:

Peptic Ulcer with ciccatrization

Investigations

Baseline:

• CBC- TC, DC, ESR, Hb%
• Blood- Sugar, Urea
• Serum Creatinine, Electrolytes
• Urine – Albumin, Sugar

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• Blood grouping and typing
• X-Ray Chest
• ECG

Specific:

• Upper GI Endoscopy
• Barium Meal

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• X-ray Abdomen
• USG Abdomen
• CT Abdomen
• Endoscopic Ultrasonogram
• Diagnostic Laparoscopy

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