Courtney Austin, MDPGY-4

LSU Internal Medicine & Pediatrics

LSU Internal Medicine Case ConferenceMay 1st, 2012

“Abdominal Pain for 2 Weeks”

Chief Complaint

46 year-old man with significant past medical history of TB (treated in prison with RIPE x 6 months) and GSW (abdomen and RLE >10 years ago) presents to the ED with complaints of nausea and abdominal pain for two weeks.

The patient describes the pain as sharp, stabbing, radiating to the back, and associated with mild nausea but no vomiting. He also states that there are no identified alleviating factors for his pain.

He also complains of early satiety for the past two weeks, with a 15 pound weight loss over the past month.

HPI

The patient denies any change in stool consistency, hematochezia, melena, or diarrhea, but does note that his bowel movements are less frequent since the onset of his poor appetite.

He was evaluated for these complaints at Ocshner Main Campus two weeks prior to his presentation, and he was prescribed a course of ciprofloxacin and metronidazole for a presumed diagnosis of gastroenteritis versus small bowel ileus.

HPI

Past Medical History:Tuberculosis, diagnosed in 2005, treated with

6 months of RIPE therapy

Surgical History:RLE Fasciotomy 2/2 GSW in 2000Exploratory Laparatomy, 2000

Family History:Maternal Grandmother with Colon Cancer

(still living post-resection)-- initially diagnosed in her 60s

Past History

Meds:Recent completion of 10-day course of

ciprofloxacin and metronidazoleDenies NSAIDs, Aspirin, and Tylenol use

Allergies:NKDA

Past History

Social History:Smokes marijuana cigarettes dailyDenies tobacco abuseDrinks 1-2 6 packs of regular beer per week, no

h/o DTsDenies any IV drug abuseHas several homemade tattoos from prisonSexually active with women, last HIV test two

years ago that patient self-reports as negativeHistory of incarceration for one year from 2004

to 2005Unemployed

Past History

Health Maintenance:Colonoscopy Not UTDInfluenza, Pneumovax Never

ReceivedTDaP UTD (2006)PCP None

Past History

Endorses: 15 Pound Weight Loss

Denies: Fever, Chills, Meningismus, Dysphagia, EpistaxisChest Pain, Dyspnea, Diaphoresis, Orthopnea, PND,

SyncopeCough, Wheezes, HemoptysisVomiting, Dysphagia, Diarrhea, Constipation,

Melena, BRBPR, Decreased Stool CaliberDysuria, Hematuria, Urinary Urgency, Flank Pain,

Penile Discharge/LesionsEasy bruising/bleeding , Recent URI/GI IllnessAnesthesia, Paresis, Paralysis, Dysarthria, Ataxia;

additional Paresthesia & Altered Sensory PerceptionDenies Recent Travel, Sick Contacts

ROS

Vital Signs & Physical Exam

Temp 97.9OF Pulse 70 RR 16BP 106/76 Pulse Ox 100% on RA BMI 21.3Weight 70 kgHeight 180 cm

Vital Signs

General:AAOx3, NAD, thin male

HEENT: NCAT, PERRLA, EOMI, Oropharynx clear, no

erythema or exudateNeck:

No LAD, no thyromegalyCardiovascular:

Regular rate & rhythm, no murmurs/rubs/gallops

Physical Exam I

Pulmonary: CTA Bilaterally, no wheezes/rhonchi/crackles

Abdomen: Decreased bowel sounds; diffusely TTP

through all four quadrants; no HSM, no masses

Extremity: 2+ peripheral pulses, no edema, no axillary

or inguinal lymphadenopathy Rectal:

Good tone, no masses, brown stool, Hemoccult® (-)

Physical Exam II

Neurologic: Motor: 5/5 upper and lower extremity, 2+

DTRsCN: PERRLA, EOMI, symmetrical facial

expression, no dysarthria, uvula midline, tongue protrusion midline, normal sensation

Sensory: intact light touch, pain, and proprioception in upper & lower extremities

Cerebellar: Intact heel to shin bilaterally, normal diadochokinesia, no tremor, no dysmetria

Normal plantar reflex bilaterally

Physical Exam III

Laboratory DataDay of Admission

Admit Laboratory Data IWBC 10.3Hgb 14.3Hct 43.9PLT 221MCV 84.3RDW 14.5

Segs70%Lymphs 16%Monos 9%

Admit Laboratory Data IINa 141K 3.7Cl 110Bicarbonate 23BUN 22Creatinine 1.08GFR >60Glucose 109

Ca++ 8.9Mg++ 1.9Phos3

Admit Laboratory Data IIITotal Protein 6.4 Total Bilirubin 1.2 Albumin 3.9 AST 17 ALT 12 Alkaline Phosphatase 49

INR 1.2Amylase 48Lipase 18

Admit Laboratory Data IVU/A

Color PaleSG 1.029pH 6.5Protein NegBlood NegUrobilinogen 1.0Ketones 15Leukocytes 25

MicroWBC 0-

2Bacteria 0-2 Squam Epi 2-

20

Admission KUB

Chest X-Ray and KUBDay of Admission

Hospital Day 1

Bowel Rest, NPO with IV FluidsHeld IV AntibioticsSymptomatic care with Nexium, Colace

Initial Management

Hepatitis Panel NegativeHIV NegativeUrine Culture NegativeUrine GC/Chlamydia Negative

Additional Laboratory Data

Unable to tolerate liquide dietAttempts to improve nutrition were made with

a nasogastric tube, which worsened the patient’s nausea and vomiting.

Repeat abdominal imagining performed 4 days after admission, prompting an interventional radiology and GI consult.

Hospital Course: Day #4

Abdominal CT with Contrast

Hospital Day #6EGD and flexible sigmoidoscopy were done to

evaluate the patient’s diffuse stomach thickening that was seen on abdominal imaging.

EGD/Colonoscopy Report

Esophagitis with slightly irregular Z-lineNodular-appearing body of the stomach

Multiple biopsies takenFindings appear consistent with gastric

Crohn’s versus infiltrative gastropathy

Pathology from EGD

Invasive adenocarcinoma, diffuse type. Chronic active gastritis and intestinal metaplasia.

Stage IV Gastric Adenocarcinoma

Final Diagnosis

On HD #10, the patient received his diagnosis, and hematology and oncology were consulted to evaluate the patient.

Due to the mainstay of life-saving therapy being surgical resection, surgical oncology was consulted and the patient was discussed at the ILH tumor board.

Careful review of the patient’s imaging with radiology revealed likely carcinomatosis from metastatic disease that spread from his stomach to the celiac plexus and head of the pancreas.

After Diagnosis

Surgery to stage the cancer was tentatively planned; however, the patient decided against a surgical staging procedure since it would not palliate his symptoms, and the surgeons were unlikely to perform a successful resection of the cancer.

After another two days in the hospital, the patient went home with hospice.

After Diagnosis

Home HospiceOncology Clinic

Discharge Follow-Up

1. Stage IV Gastric Adenocarcinoma2. Malnutrition3. Chronic Nausea

Discharge Diagnoses

Thanks For Your Attention!