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Student Grand Rounds 15/10/12

Student Grand Rounds 15/10/12. Stefanie Cachelin, Gavin Connolly, Brigid McCormack Saba Begum, Roshan Desai, Harpreet Kainth. Presenting complaint 64 yo Female Presented with sudden onset L back flank pain 8/10 severity. Collapsed whilst sitting down at work. HPC.

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Student Grand Rounds 15/10/12

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  1. Student Grand Rounds 15/10/12 Stefanie Cachelin, Gavin Connolly, Brigid McCormack Saba Begum, Roshan Desai, Harpreet Kainth

  2. Presenting complaint 64 yo Female Presented with sudden onset L back flank pain 8/10 severity. Collapsed whilst sitting down at work

  3. HPC • 2 stone weight loss over 2/12 • 2/12 HO epigastric and umbilical pain, worsened by eating, “feels like reflux”, 10/10 severity – taking oramorph and co-codamol • Pt informed us she had recent “abnormal liver levels” • Methotrexate treatment for RA • Constipated

  4. PMH • RA for past 11 yrs • Deaf in L ear since childhood

  5. DH • Oramorph 10mg 4hrly for epigastric pain • Regular cocodamol to control epigastric pain • Methotrexate 17.5mg/day for RA • Folic acid 5mg/week • Lansoperazole 30mg/day for reflux symptoms

  6. SH & FH • No drinking • No smoking • Lives with husband and has 2 children • Active – does voluntary work • Mother was diabetic and had Lung Ca

  7. On initial examination • Appears quite well, GCS 15 • Abdomen soft, no organomegaly • L renal angle tenderness – worse on movement • Constipated • No cervical, axillary or inguinal lymphadenopathy • No spinal tenderness

  8. ?

  9. 1st Differential diagnoses • Gallstones in common bile duct – abnormal liver levels and pain after eating • Autoimmune hepatitis – HO autoimmune conditions (RA) • Methotrexate SE include: abnormal LFTs Methotrexate stopped 4/7 before admission • GORD – pain after eating radiating up sternum, some reflux • Peptic ulcer – epigastric pain, pain worse after eating • Renal stone – severe left flank pain

  10. Investigations • FBC: Hb 12.4, WCC 10.9, Platelets 245, MCV 18 • LFTs: ALT 26, ALP 1100 (25-110), Albumin 34, Bilirubin 12. Alk phosphatase was 179 two months beforehand • U&Es: Na+ 138, K+ 4.1, Urea 3.9, Creatinine 54 • CRP 12 (↑)

  11. γGT: 49, slightly raised. γGTwas indicated by raised ALP – ALP is released in pathology of the bile duct and bone. Normal γGTindicates non-liver pathology as it is specific to the liver. • Bone panel: Ca2+ were at the top end of normal • XR: bone destruction and deposits suggestive of metastases; reduced disc space between L4/L5 • Abdo USS: Liver, pancreas and gallbladder normal. Small amount of free fluid in pelvis

  12. ?

  13. 2nd Differential diagnoses • Gastric malignancy ? Mets – bone destruction suggesting malignancy, epigastric pain suggesting stomach as site or origin • Myeloma – proliferation of malignant plasma cells in bone marrow causing damage to the bone structure. Indicated by back pain and vertebral collapse

  14. 2nd Differential diagnoses • Hyperparathyroidism – 80% caused by adenoma. Abdominal pain, bone remodelling • Paget’s disease – localised disorder of bone remodelling. Overactive osteoclast activity followed by compensating osteoblast acitivity. Pain in lumbar spine, hot spots on bone scan, impaired hearing

  15. Further investigations • Gastroscopy – due to epigastric pain, new onset dyspepsia in >50s requires 2WW gastroscopy. Showed ulcer ?malignant gastric ulcer • Biopsy from gastrocopy – awaiting immunohistology results • Whole body CT – due to bony deposits on XR. Showed multiple bony deposits and L gastric, coeliac and retroperitoneal LN • MRI spine - showed infiltration of axial skeleton bone marrow and a small, anterior paraspinal mass around L4 • Further blood tests: Free T4 13.6, TSH 1.5, ALT 45, ALP 1557 (↑), CRP 16 (↑), Alb 35, Ca2+ 2.61

  16. ?

  17. 3rd Differential diagnoses • Primary gastric cancer with mets to bone – poor prognosis. Doesn’t usually metastasise to bone. Bone mets are usually due to breast, bronchi, kidney, thyroid or prostate • Gastric met from unknown primary, ?breast • Neuroendocrine tumour – most common in GI system, more likely to met to bone eg. Gastrinoma. Better prognosis

  18. Diagnosis • Biopsy immunohistology report: “fragments of specialised gastric mucosa, lamina propria contains adenocarcinoma cells in single forms with occasional signet ring-like cells. AE1/AE3 immunostaining highlights adenocarcinoma cells. No evidence of dysplasia in background mucosa” • Gastric primary adenocarcinoma

  19. Treatment options • Referred to Christie’s for palliative chemo. • Surgery is best option when operable and not metastasised • Palliative chemo may include Epirubicin, Cisplatin or infusional 5-fluorouracil – suitable for the younger, fitter pt • Pain relief

  20. Prognosis • Average 5-year survival is 5%-15% • 80% of gastric cancers are diagnosed at Stage 4 – with metastases. 5-year survival is <5% and usually not more than 2 years • Adenocarcinoma being checked to see if it is HER2 positive (10% of gastric tumours). Chemo and Herceptin therapy give improved longevity of 6-12 extra months

  21. Learning points • Sources of raised ALP • Cancers that cause bone mets • Referral guidelines for gastroscopy • Gastric cancer – prevalence, presenting symptoms, aetiology, diagnosis, red flags for gastroscopy

  22. References • http://cancerhelp.cancerresearchuk.org/type/stomach-cancer/treatment/statistics-and-outlook-for-stomach-cancer

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