Clinicopathological

Conference
PRESENTER: DR HARIS JAMSHED KHAN
FACILITATOR: DR GHULAM SIDDIQ
Demographic data
 AGE: 41 years
 Sex: Male
 Came to ER
Presenting Complaint

 Malena
 Dizziness
 Epigastric pain
 Vomiting
HOPI:

 My patient was in usual state of health 4 days back when he experienced

epigastric pain, localized and dull in nature associated with vomiting.
Vomiting was mainly food particles which was non bilious, non bloody and
non projectile. He also complained of dark coloured stools for last 4 days.
Past History

 Medical: Hypertension, psoriasis

 Surgical: Left femoral Hernia repair

Family History

 Father: Diabetes, IHD

 Mother: HTN
Drug History

 Norvasc 10mg per day

Allergies

 Drugs: NKDA
 Food: Mutton, Mushroom, Fish
Socio-Economic History

 Married
 4 children
 No addictions
Personal History

 Sleep habits are normal

General Physical Examination

My patient is a middle aged pale looking male

Having normal height and built
Alert and oriented according to the time, place and person
Lying down supine on the bed
VITALS:
BP: 110/70 mmhg
PULSE: 110 beats per min
Temp: afebrile
R/R: 20 breaths per min
 Abdomen: soft nontender non distended
 CVS: S1+S2+0
 Chest: NVB,B/L clear
 CNS: GCS 15/15
DIFFERENTIAL DIAGNOSIS

 GASTRIC ULCER
 DUODENAL ULCER
 LEIOMYOMA
 LEIOMAYOSARCOMA
 PRIMARY CARCINOMA OF DUODENUM
INVESTIGATIONS

 LABORTARY Hb:7.2 TLC:11000 Platelets:308k

 Na:138 K:4.13 Cl:105 Urea:58 Cr:0.55
 UPPER GI endoscopy: Mild pangastritis(mild diffuse mucosal edema with
minimal erythema throughout stomach)
 Centrally necrotic, peripherally enhancing mass, 6x7x6.9 cm, inseparable
from and protruding into third part of duodenum causing mass effect on
adjacent structures. Multiple engorged vessels along its inferior aspect
running along anterior and posterior wall of duodenum, having no arterial
extravasation of contrast into the duodenum.
 Cholelithiasis and right renal calculus
 Suggestion of small hiatal hernia along the right aspect of the distal
esophagus likely due to tortuous esophagus.
OPERATIVE FINDINGS

 Highly vascular, about 8x6 cm near the DJ flexure, rising retroperitoneally.

 Tumor was invading third part of duodenum and densely adherent with
unsinate process of pancreas.

PROCEDURE NOTES:
 Midline incision was made.
 Tumor was noted at DJ flexure and sent for frozen section which reported it
to be malignant.
 Duodenum was cauterized and tumor was mobilized.
 Resection was done proximally between third and fourth part of
duodenum and distal resection was done up till proximal jejunum.
 Jejunum was brought to the right side and duodeno-jejunostomy was
made.
 2 drains were placed on either side retro-peritoneally.
POST-OP COURSE

 Post operatively, patient was given IV fluids.

 IV antibiotics
 IV analgesics
 Blood was transfused
 CBC, CHEM 7, PT and INR were checked.
 DVT prophylaxis
 1st POD: Rt drain:210ml Lt drain:140ml NG:100ml
 Left drain was removed 4th POD
 Sips of water were allowed on 4th POD
 Right drain was removed 6th POD
HISTOPATHOLOGY

 Gastrointestinal stomal tumor,mixed(epithilloid and spindle cell type)

 Necrosis was present upto 2%
 Margins were not involved by far GIST
Gastrointestinal Stromal tumors

 Mesenchymal neoplasms of the gastrointestinal tract.

 10-20 per one million people

 Genetics
KIT (85%)
PDGFRA (10%)
BRAF (rare)

 Origin: Interstitial cells of cajal

 Most common location : stomach

 Most common metastatic site: Liver
Signs and symptoms

 Abdominal pain
 GI bleeding
 Rarely obstruction (due to outward growth pattern)
 Dysphagia
Diagnosis

 Abdominal X-ray- obsolete

 CT scan (size , local invasion , metastasis) 87% sensitivity
 MRI-only for large tumors to determine origin.
 Biopsy
Management

 Surgery
 Chemotherapy
THANKYOU