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GOOD MORNING

GOOD MORNING. MEDICAL GRANDROUNDS ERNEST JOEL SAMACO M.D. FEBUARY 1, 2007. GENERAL DATA. A.G. 51 MALE MARRIED CATHOLIC EMPLOYEE KAWIT CAVITE. CHIEF COMPLAINT. ABDOMINAL PAIN. Objectives.

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GOOD MORNING

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  1. GOOD MORNING MEDICAL GRANDROUNDS ERNEST JOEL SAMACO M.D. FEBUARY 1, 2007

  2. GENERAL DATA A.G. 51 MALE MARRIED CATHOLIC EMPLOYEE KAWIT CAVITE

  3. CHIEF COMPLAINT ABDOMINAL PAIN

  4. Objectives • To present a case of a female patient with a giant malignant gastrointestinal stromal tumor of the jejunum • To discuss the approach to patients with abdominal pain - its evaluation and management • To discuss the management of gastrointestinal stromal tumor.

  5. HISTORY OF PRESENT ILLNESS • Three month5 day hx abdominal fullness appetite irregular bowel movement (-) nausea, vomiting, fever (-)early satiety,melena,hematochezia , + domperidone 10mg 2 tab + consult AMD Imp: Acid Peptic Disease PFA: Ileus Ranitidine 1 tab BID x 1week Pineverium bromide x 3 days Domperidone 10 mg TID

  6. PFA • Reflex Ileus • Right Pelvic Calcification R/O Distal Calculus in the distal end of the right ureter

  7. Two month + still with abdominal fullness occassional crampy RUQ abdominal pain, PS 7-8/10 re-consulted AMD s/p gastroscopy dx duodenal ulcer; negative H.pyolri Esomeprazole 20mg BID; domperidone 10mgTID ac; rebamipide 100mg TID ac symptoms improved

  8. One monthrecurrence abdominal fullness Repeat gastroscopy done showed healing duodenal ulcer, gastritis Esomeprazole 40mg OD x 4 wk • 2 weeks PTAprogressive bloatedness constipation • Night PTAabdominal pain 10/10 localized at the LUQ associated with severe bloatedness and nausea • Persistence of symptoms prompted consult

  9. Review of Systems (-) fever (-) chest pain (-) cough (-) DOB (-) easy fatigability (-) urinary changes (+) weight loss

  10. Past Medical History • (+) HPN, HBP: 160/100 NBP: 130/90 on metoprolol 50mg 1/2 tab BID and valsartan+HCTZ 160/2.5mg OD • (-) DM • (-) PTB, Bronchial Asthma, allergies • (-) previous surgery • Denies use of NSAID

  11. Family History • (-) HPN, DM, Asthma • (-) Cancer Personal Social History • (-) smoker • (-) drinker • No food preference • Denies exposure to chemicals

  12. Physical Exam • Conscious coherent, not in CRD • BP: 130/90 HR: 76 RR: 20 T36.2 • Ht 5’8” Wt 188 lbs BMI 28.9 • SHEENT: anicteric sclerae, pink palpebral conjunctivae, No CLAD, flat neck veins • C/L: no spider naevi noted, symmetric chest expansion, clear breath sounds • Heart: adynamic precordium, distinct heart sounds, NRRR, no murmur.

  13. Abdomen: Globular (40.4 inches), normoactive BS, no abdominal bruit, soft, (+)direct tenderness LUQ, (-) rebound tenderness, (-) Murphy’s and Mc Burney’s signs, tympanitic,(-) shifting dullness, (-)organomegaly/mass • Ext: Full equal pulses, Pink nail beds, (-) edema • Rectal: Good sphincter muscles,(-) tenderness, (-)mass, (-) blood on examining finger

  14. Salient Features • 51 male • Abdominal pain (LUQ) • Severe bloatedness • Nausea • constipation • (+) weight loss 6 lbs 3 months • PUD S/P EGD • Hypertensive • No family history of cancer • Abdomen: globular (40.4inches), direct tenderness LUQ

  15. Admitting Impression • Irritable Bowel Sydrome • Acid Peptic Ulcer disease (s/p Gastroscopy 9/06 & 10/06) • Hypertensive Cardiovascular Disease

  16. Course in the wards

  17. At the ER • Diagnostics: CBC, Serum Na, K, lipase, ECG, CXR • NPO • IVF: D5MM 1L x 8 • Meds: Tramadol 50mg IV q 8 Esomeprazole 40mg IV OD Metoclopromide 10mg IV q8

  18. Serum K: 2.5 (corrected 20 meq IV and kalium durules) • Serum Na: 135 • Lipase:16 • Urinalysis: Normal • CBC

  19. ECG 11/12

  20. CXR

  21. PFA and CT scan • C/O radiology dept

  22. PFA result • Hazziness seen in the hypogastrium extending to the right psoas • Ileus

  23. CT Scan whole abdomen • 12.7 x 21.9 x 19.5 cm lobulated heterogeneously enhancing abdominopelvic mass, abutting anterior abdominal wall r/o lymphoma , teratoma. • Diverticlosis, sigmopid colon • Areas of consolidation with ground glass opacities lateral and postero-basal segments, right lower lobe and postero-basal segments, left lower lobe. Consider pneumonic process.

  24. Surgery referral • Abdominal mass with signs of obstruction • maintained on NPO • Interventional radiology referral • CT scan aspiration biopsy • Consistent with Gastrointestinal Stromal Tumor • Exploratory Laparotomy with adhesiolysis, Biopsy of mesocolon nodules, Debulking of intrabodominal tumor,with resection of distal jejunum, Appendectomy, end to end anastomosis of distal jejunum

  25. Slightly sero-sanguinous ascites about 100cc • (+) fleshy friable lobulated tumor apparently invading/arising from small intestine about 6 feet from ligament of trietz with cavity containing abscess • Multiple flabby nodules scattered around mesocolon mesentry and anterior abdominal wall

  26. Surgical Pathology Picture • C/O pathology

  27. Surgical Pathology Report • Malignant gastrointestinal stromal tumor (CD-117 and Vimentin positive) • Acute Appendicitis with lymphoid hyperplasia • Malignant gastrointestinal stromal tumor, tissues labeled mesocolic nodules • Immunohistochemical Stain • Vimentin (+) • CD117(+)CK (AE1/AE3) (+)

  28. Referred to Oncology • Suggest to start Imatinib Mesylate 400meqs/day 2-3 weeks post operation • Post operatively, the course in the wards were unremarkable. • Discharged Improved 15th HD

  29. Abdominal pain/ LUQ Bowel/Colon: IBS Fecal Impaction Tumor diverticolosis GB/Pancreas: Cholecystolithiasis Acute pancreatitis Stomach: Peptic ulcer Tumor ultrasound CT ERCP barrium enema Endoscopy PFA Endoscopy Upper GI Series

  30. FINAL DIAGNOSIS 1.GASTROINTESTINAL STROMAL TUMOR 2. INTESTINAL OBSTRUCTION 2 TO JEJUNAL TUMOR 3. S/P EXPLORATORY LAPOROTOMY WITH COMPLEX ADHENOLYSIS AND DEBULKING OF TUMOR AND JEJUNAL RESECTION 4. Hypertension Stage II

  31. DISCUSSION • Indication for Endoscopy and Colonoscopy • Management of Gastrointestinal Stromal Tumor

  32. Indications for EGD American Society for Gastrointestinal Endoscopy. Appropriate use of gastrointestinal endoscopy. Gastrointestinal Endoscopy 2006;52:831-7.

  33. EGD is generally indicated for evaluating: A.Upper abdominal symptoms that persist despite an appropriate trial of therapy B.Upper abdominal symptoms associated with other symptoms or signs suggesting serious organic disease (e.g., anorexia and weight loss) or in patients >45 years old C.Dysphagia or odynophagia D.Esophageal reflux symptoms that are persistent or recurrent despite appropriate therapy E.Persistent vomiting of unknown cause G.Familial adenomatous polyposis syndromes H.For confirmation and specific histologic diagnosis of radiologically demonstrated lesion I.GI bleeding J.When sampling of tissue or fluid is indicated K.In patients with suspected portal hypertension to document or treat esophageal varices

  34. L.To assess acute injury after caustic ingestion M.Banding or sclerotherapy of varices N.Removal of foreign bodies O.Removal of selected polypoid lesions P.Placement of feeding or drainage tubes Q.Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilation systems using guidewires) R.Management of achalasia T.Palliative treatment of stenosing neoplasms

  35. Colonoscopy Indications* American Society for Gastrointestinal Endoscopy. Appropriate use of gastrointestinal endoscopy. Gastrointest Endosc 2006;52:831-7.

  36. A..Evaluation on barium enema or other imaging study of an abnormality that is likely to be clinically significant, such as a filling defect or stricture B..Evaluation of unexplained gastrointestinal bleediNG C.Unexplained iron deficiency anemia D..Screening and surveillance for colonic neoplasia 1.Screening of asymptomatic, average-risk patients for colonic neoplasia 2.Examination to evaluate the entire colon for synchronous cancer or neoplastic polyps in a patient with treatable cancer or neoplastic polyp 3.Colonoscopy to remove synchronous neoplastic lesions at or around time of curative resection of cancer followed by colonoscopy at 3 years and 3-5 years thereafter to detect metachronous cancer 4.After adequate clearance of neoplastic polyp(s) survey at 3- to 5-year intervals

  37. 5.Patients with significant family history a..Hereditary nonpolyposis colorectal cancer: colonoscopy every 2 years beginning at the earlier of age 25 years or 5 years younger than the earliest age of diagnosis of colorectal cancer. Annual colonoscopy should begin at age 40 years. b.Sporadic colorectal cancer before age 60 years: colonoscopy every 5 years beginning at age 10 years earlier than the affected relative or every 3 years if adenoma is found 6.In patients with ulcerative or Crohn's pancolitis 8 or more years’ duration every 1-2 years with systematic biopsies to detect dysplasia E.Clinically significant diarrhea of unexplained originF.Intraoperative identification of a lesion not apparent at surgery

  38. G.Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasia, and polypectomy site H.Foreign body removal I.Excision of colonic polyp J.Decompression of acute nontoxic megacolon or sigmoid volvulus K.Balloon dilation of stenotic lesions L.Palliative treatment of stenosing or bleeding neoplasms M.Marking a neoplasm for localization

  39. Management of Gastrointestinal Stromal Tumor CONSENSUS MEETING FOR MANAGEMENT OF GIST REPOST OF THE GIST CONSENSUS CONFERENCE MARCH 2004 UNDER THE AUSPICES OF ESMO Annals of Oncology 2005 16(4);566-578

  40. Introduction • 1983 describes as tumors in GIT and Mesentery • Characterized by specific histological and immunohistochemical pattern • Median age of 60 year old • Incidence of 10 cases per 1 million which approxiately 1/3 are malignant • Male predominance • The stomach is the most common site for GITS, with the small bowel being the second most frequent location • GITS tumor constitutes 1%-3% of all gastric tumors and develop from the intestinal cell of Cajal ( or pacemaker cells) • They maybe benign or malignant and presents with GI bleeding (40%), abdominal mass (40%), or abdominal pain (20%).

  41. Histologic Criteria for GIST • Spindle cell (70%) • Epitheliod type (20%) • Mixed cell type (10%) • Immunohistochemical staining • CD 117 (+ in 95% cases) • CD34 (+ in 70% cases) • Smooth muscle actin (+ in 40% cases) • PS100 (+ in 5% cases) • Desmin (+ in 2% cases)

  42. Prognositc value of grading is unclear • GIST from small intestine worse prognosis compared to gastric GIST • 5 Year survival rate approximately 35-65% among patient complete resection • Median survival 10-20 months with unresectable disease

  43. Is molecular biology for KIT and PDGFR mutation a diagnostic or research procedure for GIST?

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