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case conference: inflammatory pseudotumor of the stomach


									                              DR. JOSE R. REYES MEMORIAL MEDICAL CENTER
                                        DEPARTMENT OF SURGERY

General Data: This is a case of FM, 63/F, married, Roman Catholic from Malolos, Bulacan who was
admitted at our institution for the first time on March 15, 2009.

Chief complaint: abdominal mass

History of Present Illness:

        The patient was apparently well until

         8 months PTA, patient noted palpable mass at the epigastric region. The mass was described to
be palpable,solitary, movable and non tender. There were no associated vomiting, weight loss, nor easy
satiability. No consult was done nor medications were taken.

         2months PTA, persistence of the above mentioned complaints prompted consult at our
institution. Ultrasound was done revealing a solitary solid mass with surrounding fluid at the left lobe of
the liver. CT Scan was also requested revealing gastric vs hepatic mass. The patient was then advised to
have an EGD done.

        1 month PTA, endoscopy was done which showed an extraluminal compressing mass at the
antral-pyloric area. Biopsy was done which revealed chronic inflammation with fibrosis, negative for
malignant changes. Patient was advised operation.

        Few days PTA, patient experienced pain over the epigastric mass.

Review of Systems:

(-) fever                             (-) chest pain                        (-) hematemesis
(-) anorexia                          (-) orthopnea                         (-) hematochezia
(-) weight loss                       (-) PND                               (-) melena
(-) malaise                           (-) dysphagia                         (-) weight loss
(-) headache                          (-) odynophagia                       (-) urinary changes
(-) dyspnea                           (-) hoarseness                        (-) constipation

Past Medical History:

        S/P Excision of TB adenitis 20 years ago
        S/P EGD with biopsy (2/23/09 JRRMMC)
        (-) DM, HPN, HD, BA, CVD, PTB

Family Medical History:

        (-) HPN, HD, DM, BA, CA, PTB, CVD
Personal and Social History:

       Non-smoker and non-alcoholic beverage drinker, denies illicit drug used

Physical Examination:

       Awake, conscious, coherent, ambulatory
       BP- 130/80        HR-80 RR-19 T-afebrile           Ht-1.57m       Wt- 47kg       BMI-19
       Pink palpebral conjunctivae, anicteric sclera, no lymphadenopathies, no TPC
       No alar flaring, no retractions, ECE, CBS, no rales, no wheezes
       No heaves, no thrills, AB at 5th ICS LMCL, distinct heart sounds, normal rate and regular rhythm,
       no murmurs
       No scars, Flat abdomen, NABS, (+) 2x2 cm mass at the epigastric area movable nontender, NABS,
       no hepatomegaly, no tenderness
       Pink nailbeds, no jaundice, full and equal pulses

Admitting Diagnosis:

       Antral-pyloric mass

       T/C Ca

Course in the wards:

Hospital Day 1
        S>     67/F complaining of abdominal mass, no other associated symptoms
        O>     BP = 130/90, HR 82, RR=20, T= 36.8,
               essentially normal physical exam except for 2x2 cm epigastric mass
        A>     Gastric Mass T/C Malignancy
        P>     DAT, secure OR needs

Hospital Day 2
        S>       no subjective complaints, seen by anesthesia
        O>       stable vital signs
        A>       same
        P>       preop meds ordered, NPO postmidnight, venoclysis started

Hospital Day 3
        S>     underwent operation
        O>     BP=130-160/80-90, HR=80-110, RR=20-24
        A>     Same + S/P Exploratory Laparotomy, Frozen section of antral-pyloric mass,
               subtotal gastrectomy, Billroth I, JP drain.
        P>     Tramadol 50mg IV LD as LD then 250mg D5W 500cc x 15ugtts/min
               Ranitidine 50mg IV q12
               Cefoxitin 1g IV q8
               For post op CBC, Na, K
Hospital Day 4
        S>     1st post op day, afebrile, (-) BM, (-) flatus, VAS =8/10
        O>     soft flat abdomen, hypoactive bowel sounds, minimally soaked dressing with blood
               JP drain output:144 cc serous
        A>     same
        P>     NPO
               daily wound care
               deep breathing exercise
               ambulation encouraged
               IV meds continued
               D10W 10cc q2 per NGT started
               tramadol drip to increased to 20ugtts/min
               NSS (2cc) nebulization q6 initiated

Hospital Day 5
        S>     2nd Post op day, (-) nausea, (-) vomiting, (+)minimal to moderate operative site pain,
               (-)BM, (-) flatus
        O>     afebrile, soft and flat abdomen, hypoactive bowel sounds, JP output=38cc serous
        A>     same
        P>     NPO
               Cont. IV meds
               foley catheter removed
               Daily wound care
               NGT feeding increased to 30 CC q2

Hospital Day 6
        S>       3rd post op day, (-) nausea, (-)vomiting,(-)BM, (-)flatus, minimal operative site pain
        O>       afebrile, soft and flat abdomen, hypoactive bowel sounds, JP output= 14 cc serous
        A>       same
        P>       NPO
                 IVF continued , Cefoxitin consumed
                 D10W x 50ccq2

Hospital Day 7
        S>       4th post op day, (+) flatus , (-) vomiting, (-) abdominal pain, NGT pulled out
        O>       afebrile, , (-) BM, soft abdomen, hypoactive bowel sounds, JP output: 10 cc
        A>       same
        P>       Clear liquids with SAP
                 Ranitidine and Tramadol drip continued

Hospital day 8
        S>     5th Post op day (-) nausea, (-) vomiting, (-) abdominal pain, (-) abdominal distention,
               (-) fever, (+) BM, (+) flatus
        O>     soft abdomen, normoactive bowel sounds, dry well coaptated wound,
               JP output: 44 cc
        A>     same
        P>     GL-SD-DAT
                  IVF and IV meds consumed
                  Start Etoricoxib 120mg/tab 1 tab OD

Hospital Day 9
        S>         6th Post OP day, (-) fever, (+) BM, (+) flatus
        O>        normoactive bowel sounds, dry well coaptated wound, (-) discharge/surgical site
        A>        same
        P>        DAT
                  Pull out JP drain prior to discharge
                  Discharged improved
                  Scheduled for OPD ff-up after 1 week



Date            Normal                       2/25/09       3/17/09
WBC             5-10 x109/L                  10.7          16.50
RBC             4.2-5.4 x109/L                             3.78
Hgb             120-160g/L                   120           113
Hct             0.38-0.47%                   0.36          0.34
Platelets       150-400 x109/L                             188
Neut%           0.5-0.7                                    .88
Lymph%          0.2-0.5                                    .07
Mono%           0.02-0.09                                  .05
Eo%             0.0-0.06                                   .00
Baso%           0.0-0.02                                   0.00

DATE              Normal              1/13/09       2/25/09
Protime Ctrl      10-14 secs          14.01         14.17
Patient                               17.51         15.0
Activity                              79%           92%
INR              1.0                  1.40          1.10


Date             Normal          1/13/09        2/25/09
Control                          23.4-36.2
Patient                          32.21          28.29

Date          Normal                         1/13/09      1/20/09    1/22/09   2/25/09   3/17/09
Glucose       65-110mg/dL                    96.18                             95.09
BUN           7-17 mg/dL                                  10                   12.61
Creatinine    0.7-1.2mg/dL                                1.1                  1.08
Sodium        135-145mmol/L                                                    136       142
Potassium     4.0-4.5mmol/L                                                    4.8       3.5
Total protein 6.6-8.7g/dL                    7.59                    7.49
Albumin       3.8-5.1g/dL                    2.29                    5.39      5.32
Globulin      2.8-3.6g/dL                    2.30                    2.10
Date                Normal               2/25/09
Color               Yellow               Yello
Transparency        Clear/hazy           Slightly
SG                  1.016-1.022          1.010
pH                  4.6-6.5              7.0
Sugar               (-)                  (-)
Albumin             (-)                  Trace
RBC                 0/0-2/hpf            5-10
WBC                 0-2/0-5/hpf          1-2
Casts               hyaline, coarse,     None
                    fine, granular,
                    RBC, WBC, waxy
Crystals            Small amounts        Amorphous
Epith cells         Small amounts        (+)
Bacteria            (-)                  (-)
Mucus thr           Small amounts


Marker              Normal                   Result
CEA                 0-3.4ng/ml               2.28
AFP                 0-8.5ng/ml               0.1

Date    Exam                Results

1/13/09       CXR           Atheromatous aorta

1/15/09       Whole         Liver is normal in size with rounded solid echopattern surrounded by anechoic or fluid echo in the left
              abdominal     lobe 3.7 x 2.9 cm in size; ducts and portal vessels not dilated, gallbladder 5 x 2 cm x 1.2 cm in size no
              UTZ           stones, wall nott thickened; pancreas normal in size and echogenicity; spleen not enlarged with normal
                            echopatttern. Bilateral kidney, small or tiny lithiasis, ureter not dilated, normal bladder; uterus small
                            and atrophied; ovaries not enlarged

                            Impression: 1. Consider solitary solid mass with surrounding fluid left lobe liver 2. Small or tiny lithiasis
                            both kidneys 3. Gallbladder, pancreas, spleen, ureters, urinary bladder, ovaries are unremarkable 4.
                            Small atrophied uterus

1/21/09       CT Scan of    4 x 3.5 cm minimally embracing isodense fairly defined soft tissue forms at epigastric region,
              the           inseparable with the gastric antralpyloric portion and the Left Liver lobe; Normal parenchymal
              Abdomen       attenuation with smooth contour, intrahepatic ducts not dilated; gallbladder normal in size and
                            configuration, wall not thickened, no stones;unremarkable pancreas, adrenal glands, spleen, no
                            calcifications; slightly enlarged peripancreatic, paraaortic and aorto-caval nodes seen, no
                            infiltration/thickening of mesenteric fat; unremarkable kidneys, proximal ureters are normal; opacified
                            stomach appears to have thickend wall with fullness seen at its antral-pyloric portions; urinary bladder
                            well opacified with smooth wall

                            Impressions: Left liver lobe vs. gastric antral pyloric mass

2/25/09       CXR           Atheromatous aorta, normal chest findings
Date     Exam      Results

2/26      ECG         Normal sinus rhythm with occasional PAC, NSSTTWC

EGD with Biopsy (Feb 23, 2009): Chronic inflammation with fibrosis, negative for malignant changes


        Gross. Specimen consist of a segment of the gastric measuring 14x7.5x 4.5 cms. External surface
shows rubbery, smooth, tan-brown. Cut section shows prominent edematous mucosal folds with
thickened muscular wall near the distal line of resection measuring 4.0 x 3.5cm smooth with white
streak surface.

       Microscopic. Microsections show proliferationof plump to elongated myofibroblasts arranged in
short fascicles embedded in a collagenous stroma are numerous lymphoplasmacytic infiltrates
penetrating the muscular wall. Some areas of the gastric muscular have been replaced by
myofibroblastic proliferation.


                Inflammatory Pseudotumor

                Frozen Section Diagnosis: Malignant T/C Gastrointestinal Stromal Tumor

                Remarks: Request for Vimentin and smooth muscle actin immunistatins for more

                definitive diagnosis.

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