Patient presented with 5 months history of progressive abdominal pain associated with per rectal bleeding and early satiety for 1 month duration.

1. INTRODUCTION
Name : D M A
Age : 59 years old
Gender : Male
Race : Malay
Occupation : Pensioner
Address : Taman Haji Ahmad 3, Kuantan, Pahang.
Date of admission : 23th March 2015
Date of Clerking : 26th March 2015
HISTORY
CHIEF COMPLAINT
Patient presented with 5 months history of progressive abdominal pain associated with per
rectal bleeding and early satiety for 1 month duration.
HISTORY OF CHIEF COMPLAINT
Patient was apparently well until 5 months ago, when he experienced abdominal pain that is
generalized as he unable to pinpoint the location of the pain. The pain was sudden in onset, colicky
in nature and gradually increasing in severity. However, he still able to tolerate the pain and it did
not affect his daily activities. Around 3 months after the onset of the symptom, the pain which is
initially generalized had radiated to the epigastric region. The pain had been burning in nature and
aggravated by food ingestion especially spicy and salty food. He then went to a nearby Klinik
Kesihatan and was prescribed with a medication. The symptom was noted to be relieved by the
medication. There was no episode of nausea or vomiting, water brash or heartburn sensation.
Around 1 month prior to admission, patient developed a new onset of passing out painless
per-rectal bleeding in a form of black-tarry stool. It was dark and mixed with his stools. He noticed
that his stool smells awfully disturbing and become stickier. The frequency of bowel output
however not changes as patient usually passes motion around once in two days. After passing out

2. the black-tarry stool, he experienced palpitation, dizziness and syncope attack in which he needed
to lie down to prevent from fall. There is no however episode of vomiting out blood, yellowish
discoloration of the eye and skin, and no right hypochondriac pain. He also denied any episodes
of epistaxis, bleeding gum or easily bruising. There was no associated tenesmus and passing out
mucus.
Since the beginning of the onset of the per-rectal bleeding, he never went to seek for medical
attention as he claimed that in between the per-rectal bleeding, he was feeling well. Until after a
month of the onset of per-rectal bleeding that he noticed that he had some weight loss by the
reduction in his pants size that is also associated with loss in appetite. The amount of food intake
has also reduced as he felt easily full. This condition was also noticed by his daughter who brought
him to the hospital and during admission, several investigations had been done to clarify the cause
of his per-rectal bleeding.

3. SYSTEMIC REVIEW
Skin Skin was normal with no change in the color and contour. There was
also no itchiness noted.
Head There were no swellings or any injury of the face.
Eyes There was pallor, but no jaundice, no redness or any discharge from the
eyes.
Ears There was no discharge or hearing impairment.
Nose There was no discharged, nose block, bleeding or odor from the nose.
Mouth and
throat
There was no any odor.
Neck The neck region was normal. There were no any swellings or stiffness.
Respiratory
system
There were no episodes of cough, breathlessness, noisy breathing or
hemoptysis
Cardiovascular
system
There was palpitation, but no dyspnea, orthopnea, cyanosis, or chest
pain.
Hepatobiliary
system
The patient has no jaundice.
Hemopoietic
system
This system was intact with no jaundice or bleeding tendency
Neuromuscular
system
This system was intact with no swelling and weakness of muscles, bones
and joints. There were also no abnormality of movements and
coordination.
Urologic
system
Patient had episodes of gradually increasing in difficulty of passing
urine but with no episode of dysuria or hematuria.
PAST MEDICAL HISTORY
He is a known case of diabetes mellitus which is diagnosed 10 years ago. Currently he is on
single type of oral hypoglycemic agent. Otherwise, he is not known to have hypertension, ischemic
heart disease or malignancy. There is also no history of blood transfusion.

4. PAST SURGICAL HISTORY
He has no previous history of hospitalization. He also never underwent any form of surgical
treatment or intervention.
DRUG AND ALLERGY HISTORY
For the past 10 years, he had been taking his oral hypoglycemic agent regularly. For the past
1 year, he had been taking commercial health supplement in a form of soluble powder that is taking
daily. Otherwise, there is no history of chronic ingestion of non-steroidal anti-inflammatory drugs
(NSAIDs) for any reason. He has no known allergies towards drugs or foods.
FAMILY HISTORY
There is no family history of chronic disease such as diabetes mellitus, hypertension and
ischemic heart diseases running in the family. There is also no known family history of
gastrointestinal malignancy.
SOCIAL HISTORY
He is a pensioner who previously worked as an owner of a restaurant. Currently the restaurant
is run by his son. He lives in a single storey-house at Taman Haji Ahmad with his wife and his 4
children. He is a heavy smoker that smokes around 2 packs of cigarettes per day. Otherwise, there
is no history of chronic alcohol consumption, tattooing or high risk behaviors.

5. PHYSICAL EXAMINATION
GENERAL
Patient was lying comfortably in supine position. He was alert, conscious and oriented to time,
place and person. He was not in pain or in respiratory distress. There was a peripheral cannulation
located at the dorsum of his right hand with no active infusion. He looked pale but no jaundice
noted. There was also wasting over the temporalis muscle. There was also evidence of impaired
nutritional status from wasting of both thenar and hypothenar muscle. The hydration status of the
patient was however good.
There were no stigmata of liver disease noted such as flapping tremors, loss of axillary hair
and spider nevi. There were also no bruises over the upper and lower limb. There was no injection
marks and tattoo noted. There was also no pedal edema.
VITAL SIGNS
Blood pressure : 126/88 mmHg
Pulse rate : 88 beats/ minute, good volume and regular rhythm
Temperature : 37oC
Respiratory rate : 16 breathe/ minute
PERABDOMINAL EXAMINATION
The abdomen was not distended. There were no abnormal skin changes, scars or dilated veins.
The cough impulse was negative. The abdomen was soft and non-tender. There was a vague mass
located at the epigastric area that didn’t move with respiration. The mass was not pulsating. The
mass was hard and with irregular margin. The surface was unappreciable. There was dullness over
the mass with percussion, Succussion splash test was negative. Otherwise there was no bruit heard
over the mass. Otherwise there was no hepatomegaly and splenomegaly. Both kidneys were not
ballotable. There is negative shifting dullness. The bowel sound was present. The left
supraclavicular lymph node (Virchow’s gland) was not palpable.

6. DIGITAL RECTAL EXAMINATION
On inspection, there was no skin rashes, excoriation, mass, scars, fistula or fissures. However,
a small skin tag was seen at 6 o’clock position. There was no fecal soiling, blood or mucus
discharge.
Upon digitation, the tone of the sphincter was present and normal. Prostate gland was enlarged
but symmetrical. The surface is smooth and firm to consistency. The median sulcus was palpable.
Otherwise the rectum was empty with no masses felt. Upon removal the finger, there was dark
brownish feculent stain over the finger.
RESPIRATORY EXAMINATION
The chest was normal in shape with no scars of dilated veins. The chest expansion was equal
bilaterally. There is also equal vocal fremitus and both lungs field were resonance on percussion.
There is equal air entry with no added sounds was heard such as rhonchi or crepitation.
CARDIOVASCULAR EXAMINATION
The apex beat was palpable at left 5th intercostal space, midclavicular line. There are no thrills
or parasternal heave noted. Both normal heart sounds were heard with no murmurs.
NEUROLOGICAL EXAMINATION
There was normal motor function of both upper and lower limb with muscle power of 5 on all
limbs. The sensory parts were also normal with intact cranial nerve function.
SUMMARY
59 years old, Malay pensioner, a heavy smoker, with underlying 10 years history of diabetes
mellitus currently on treatment, presented with history of passing out black-tarry stool for 1 month,
associated with anemic symptoms, loss of weight and loss of appetite, and epigastric abdominal
pain. There are no symptoms of metastasis. There is no family history of malignancy. Physical
examination revealed vague and hard epigastric mass that is not moving with respiration.

7. PROVISIONAL DIAGNOSIS
Carcinoma of the Stomach
Reasons favoring: First is his age group. Incidence of carcinoma of the stomach peaks around the
age of fifty to seventy. He had central pain initially and become more localized to epigastric pain,
which is the characteristic of the pain change from colicky to burning pain. The pain also
exacerbated by eating. The pain was also not periodic, in comparison to peptic ulcers. Loss of
appetite and loss of weight is the cardinal symptom of stomach cancer and usually occurs long
before any other symptoms arise. He also has symptoms of upper gastrointestinal bleeding which
is black tarry stool and symptoms of anemia. He is also a smoker which is one of the risks to get
stomach carcinoma. There is also vague mass palpable at the epigastric region.
Reasons against: he has no symptoms of intestinal obstruction, no altered bowel habit and he had
a vague history of gastric ulcer.
DIFFERENTIAL DIAGNOSIS
1. Peptic Ulcer
Reasons favoring: Firstly is his age group. Secondly, gastric ulcers usually cause loss of weight
since patients are afraid to eat and the pain is associated with food intake. Epigastric pain, vomiting
and water brash are also present in this patient, which are symptoms favorable of a gastric ulcer.
He is also anemic, that may suggest the complication of peptic ulcer which is bleeding and
manifested by black tarry stool. He is also a smoker which is one of the causes of peptic ulcer
disease.
Reasons against: The patient did not mention anything indicating a cyclic sort of pain, separated
by a certain period of time, which is a characteristic of a gastric ulcer. Duodenal ulcer patient
usually have a good appetite, and taking food relieves the pain. He also had no history of NSAID
usage, which is an important factor in the elderly.

8. 2. Esophageal varices
Reasons favoring: In the elderly; one of the commonest causes of upper gastrointestinal bleeding
is bleeding esophageal varices.
Reasons against: Patient however had no signs and symptoms suggestive of chronic liver disease,
the condition that is mostly associated with esophageal varices. He also is not known to have risky
behavior to develop chronic liver disease such as alcohol consumption and history of hepatitis.
3. Chronic Pancreatitis
Reasons favoring: Epigastric pain with significant weight loss.
Reasons against: The pain is usually marked, and relieved by bending forward. There was also no
steatorrhoea or any indication of malabsorption.
4. Carcinoma of Pancreas
Reasons favoring: Firstly is his age group which is more common at 50-70 years old. Patient also
had symptoms of chronic epigastric pain and constitutional symptoms. He is a smoker which is
one of the risk factors to get carcinoma of pancreas
Reasons against: The pain does not associate with symptoms of obstructive jaundice, steatorrhea,
diarrhea and bloating.

9. INVESTIGATION
Blood Investigation
1. Full blood count
Indication: since patient is having per-rectal bleeding and clinically symptomatic
for anemia, full blood count is taken to assess the severity of the anemia and at the same
time to assess the overall status of patient’s white cell count for infection and platelet for
coagulopathy.
Parameters (post transfusion)
Hemoglobin 6.1 7.5 8.8
Total Red Cell Count 2.25 2.90 3.54
PCV 20.3 25.6 27.1
MCV 90.2 88.3 87.7
MCH 27.1 25.9 27.5
MCHC 30.0 29.3
Total White Cell Count 8.43 9.24 8.45
Platelet 337 322 337
Impression: patient is severely anemic. Other parameters are normal.
2. Liver function test
Indication: with suspicious of malignancy, the liver function is assessed to rule out
any liver metastasis. LFT also is done to assess the nutritional status of the patient.
Parameters
Total bilirubin 3.6
Direct bilirubin 0.5
Indirect bilirubin 3.1
Total protein 64.0
Albumin 32.0

10. Globulin 32,0
AG ratio 1.00
Alkaline phosphatase 87
ALT 15
AST 22
Impression: with a normal liver enzyme level, there is no parameter showing the
presence of liver metastasis or liver involvement. The low protein and albumin level is
coinciding with the patient history of significant weight loss, suggestive of impaired
nutritional status.
3. Renal profile
Indications:renal profile can be used also to assess the nutritional and hydrational
status of the patient. Since patient also complaining symptoms of lower urinary tract
obstruction, renal profile is used to assess the condition of the kidney.
Parameters
Urea 5.5
Sodium 140
Potassium 4.2
Chloride 110
Creatinine 115
Impression: raised creatinine level in this patient may suggest an impending renal
injury, further monitoring and investigation is needed. Raised creatinine may also due to
dehydration.

11. 4. Coagulation Profile
Indication: to rule out coagulopathy as the cause of the per-rectal bleeding.
Parameters
Prothrombin time (PT) 13.8
PT ratio 1.1
INR 1.2
APTT 42.7
APTT ratio 1.1
Impression: all parameters are normal.
5. Prostate Specific Antigen
Indication: to rule out the presence of prostate carcinoma in view of
prostatomegaly and obstructive symptoms of lower urinary tract.
Parameters
PSA 1.63
Impression: parameter is normal.
Others
1. Oesophago-Gastro-Duodeno Scopy (OGDS)
Indication: as a diagnostic tool to confirm the presence of upper gastrointestinal
bleeding and to confirm the cause. OGDS also can be used to get a sample of the mucosal
layer for histopathological examination.
Impression: huge pre-pyloric tumor extending into first part of duodenum with
ulcerated area (Forest III). The tumor bleeds when biopsied. The pyloric ring was
deformed. The esophagus and the second part of the duodenum were normal.

12. 2. Histopathological Examination (HPE)
Indication: to confirm the status of the tumor whether it is a malignancy or benign
lesion. Also to assess the type of cell that made up the tumor.
Impression: poorly differentiated adenocarcinoma
3. Electrocardiogram (ECG)
Indication: as a baseline investigation and as a routine pre-operative
investigation.
Impression: normal ECG.
Imaging
1. Chest x-ray
Indication: to rule out the presence of lung metastasis from the malignancy.
It is also as a baseline investigation for pre-operative assessment.
Impression: there is no cannon-ball opacity noted on the lung field that may
suggest presence of metastasis.
2. Computed Tomography of Thorax-Abdominal-Pelvis (CT TAP)
Indication: as a staging tool of the tumor to look for local invasion, involvement of
regional lymph nodes and presence of distant metastasis.
Impression: pre-pyloric tumor with regional lymphadenopathy.
FINAL DIAGNOSIS
Pre-pyloric adenocarcinoma with symptomatic anemia

13. PRINCIPLE OF MANAGEMENT
1. Resuscitation
a. Set IV access with 2 large bore peripheral cannula.
b. Draw out some blood to send for laboratory investigation (FBC, LFT, Coagulation
profile, GSH)
c. If persistently severe anemia, transfuse patient appropriately with blood product.
2. Prepare patient for surgical intervention.
a. Radical therapy
i. Total gastrectomy
ii. Subtotal gastrectomy (Billroth II)
b. Palliative therapy
i. Palliative bypass
ii. Stenting
3. Chemotherapy and radiotherapy
SUMMARY OF PATIENT PROGRESSION
For the current admission, patient is electively admitted for operative management. Patient
had undergone several investigations and had been diagnosed as pre-pyloric adenocarcinoma of
the stomach. In the ward, blood investigation shows patient is severley anemic. Patients was then
received 2 units of pack cell and the hemoglobin level raised from 5 g/dl to 8 g/dl Patient had
undergone palliative bypass surgery (laparotomy with gastrojejunostomy and jejunojejunostomy).
Post-operatively, patient had no complications. Currently patient is still in the ward for monitoring.
DISCUSSION

14. In Relation to Disease
1) Epidemiology:
According to Dr Ramesh Gurunathan during Third Asia Pacific Gastroesophaegeal Cancer
Congress held at Sunway Medical Centre, Selangor, he said that patients with dyspeptic symptoms
should be investigated early rather than viewing the pain as a classical symptom of gastritis. Those
affected will firstly experience infection in the upper gastrointestinal tract (oesophageal and
stomach), but often only seek treatment when the stomach cancer has developed to stage II or IV.
According to studies, 82% of the patients presented with stage IV disease and curative surgery
were offered only to a 16% of them. Carcinoma of the stomach is the 10 most common fatal
cancers in Malaysia with about 1400 Malaysians developing it every year. It can occur in adults
of any age, however it is rare under the age of 50. It is more common among men than women.
Stomach cancer may affect males more because they smoke and drink more than women. In
Malaysia, stomach cancer is the seventh most common cancer in males while it is the 10th most
common cancer in females. Its prevalence in terms of ethnicity shows the highest among the
Chinese (65 per cent).
2) Aetiology and risk factors:
Until now, there are no definitive aetiological agents have been recognized to cause gastric
cancer. There are several risk factors that can be associated with the development of malignant
change in the stomach, i.e. the diet factor, H. pylori infection, benign gastric ulcer, chronic atrophic
gastritis, pernicious anaemia, and others.
Gastric cancer is noted more commonly where malnutrition is prevalent. It also has been
associated with the use of certain preservatives in food, nitrates, nitrites, and nitrosamines.
Recent epidemiological studies have suggested that H. pylori may be associated with an
increased incident of malignant change within the stomach. It may be due to its ability to produce
ammonia and other mutagenic chemical. Therefore, an investigation such as serology, histology,
or 13C tests should be done to determine either the development of gastric carcinoma is also
contributed by H. pylori infection.

15. It is thought that chronic peptic ulceration in stomach increase the risk of malignant change
within the ulcer. Same goes to chronic atrophic gastritis (CAG) which is commonly associated
with pernicious anaemia (PA). Patients with these two conditions, CAG and PA have a fourfold
increased risk of getting stomach cancer compared to normal population.
3) Pathology:
Most of gastric cancers occur in the antrum and almost invariably an adenocarcinoma. The
common type is intestinal and the tumors are polyploidy or ulcerating lesions with heaped-up,
rolled-edges.
There are two classification of gastric cancer, i.e. early and advanced gastric cancers. The
differences are stated in the table as follow:
Early gastric cancer Advanced gastric cancer
Confined to mucosa and submucosa
Have penetrated more deeply into the
stomach wall
Minor involvement of lymph nodes
metastases
Lymphatic metastases are frequently involved
No any other signs of metastases to other
organs
Associated with a variety of distant
metastases
4) Staging:
Staging in gastric cancer is done by using the CTscan of the chest and abdomen to visualize
the lungs, liver, peritoneal cavity, and perigastric and retroperitoneal lymph nodes. It can also be
done by using ultrasonography which detects small metastases within the liver.
The staging is done by referring to TNM classification as follows:
Staging Description
T
1 Tumor extends to lamina propria or submucosa
2 Tumor extends into muscles

16. 3 Tumor extends into serosa
4 Tumor extends into adjacent structure (bronchus, aorta)
N
0 No lymph nodes involvement
1 < 7nodes
2 7-15
3 >15
M
0 No metastases
1 Metastases
5) Prognosis:
In general, the prognosis of gastric cancer becomes worsened as it metastases to other
places. The table below shows the examples of gastric cancer and their prognosis.
Stage 5-year survival (%)
T1N0M0 95+
T1N1M0 70-80
T2N1M0 45-50
T3N2M0 15-25
M1 0-10
In Relation to Patient
Mr. M, a 59 years old Malay, a smoker, with underlying diabetes mellitus, was diagnosed with
pre-pyloric adenocarcinoma of the stomach. The patient which initially presented with symptoms
suggestive of peptic ulcer disease has been treated as outpatient and was given medication with no
investigations done for him. It has been proven that gastric ulcer has the tendency to undergone
malignant changes that can be detected early if the ulcer is biopsied. In elderly, it is advisable for

17. any patient presented with gastrointestinal symptom, to be investigated properly to rule out the
presence of malignancy.
With no investigation done earlier, patient eventually developed new-onset symptom of upper
gastrointestinal bleeding which is passing out black-tarry stool but no hematemesis. At this point
of disease course, prompt investigation need to be done as patient already developed symptomatic
anemia. Endoscopic study (i.e. Oesophago-Gastro-Duodeno scopy) has been chosen as the
modality. OGDS which has been chosen as it has both diagnostic and therapeutic value.
Diagnostically, OGDS can be used to demonstrate structural abnormalities of the gastric lumen.
In this patient, it has been found a presence of large tumor at the pre-pyloric area of the stomach.
At the same time of OGDS, tissue sample can be taken by the OGDS for biopsy to rule out the
presence of malignancy. The biopsied sample can further be investigated for the presence of
Helicobacter pylori which is found to cause recurrence of ulcer in 50%. In this patient,
histopathological examination of the sampled tissue shows poorly differentiated adenocarcinoma
which is the commonest type of gastric malignancy.
To further stratify the patient according to the severity of the disease, computed tomography
(CT) scan has been used to assess the local infiltration of the malignancy to adjacent organ,
regional lymph nodes and to detect the presence of distant metastasis to distant organ. In this
patient, there is regional lymphadenopathy but no presence of distant metastasis.
As the final definitive management, patient has been planned for surgical intervention. The
modality of choice can be divided into curative surgery and palliative surgery. Curative surgeries
which include total gastrectomy or subtotal gastrectomy with regional lymph node resection
requires careful staging to ensure realistic chance of cure. While palliative surgery involves the
palliative bypass surgery or stenting. The surgical intervention of choice will depend whether the
tumor is resectable or not. In this patient, initially he was planned for total gastrectomy with bypass
surgery to be put in stand-by. Intra-operatively however shows the tumor was not resectable, and
in this situation, palliative bypass surgery was the management of choice. Stenting cannot be done
for distal gastric tumor and was reserved for tumors blocking the gastric inlet.
REFERENCES

18. 1. Malaysian Oncology Society
2. Article: Gastric Cancer in Malaysia, The Need for Early Diagnosis
3. Uptodate.com
4. Principles and Practice of Surgery, 4th ed., O. James Garden, Andrew W. Bradbury, John
Forsythe, Churchill Livingstone, 2002.
5. Oxford Handbook of Clinical Surgery, 3rd Edition.
6. Oxford Handbook of Clinical Medicine, 8th Edition.
7. Kumar & Clarks’s Clinical Medicine, 7th Edition.
8. Essential Surgery; Problems, Diagnosis and Management, 4th Edition.