GASTRIC CARCINOMA

with GASTRIC OUTLET

OBSTRUCTION

J.KAVYASRI ,K.ABINAYA
A 63year old , Mr. KADHIRESAN ,who is a driver by occupation ,from
Viralimalai came to the OPD with chief complaints of vomiting for past 6
months.
HISTORY OF PRESENT ILLNESS

The patient was apparently normal before 6 months after which

he developed vomiting with 3-4 episodes per day .
The vomiting is
non projectile ,
copious in quantity ,
non-bilious,
foul smelling ,
contains partly digested food particles and occurs after >4 hours of
food intake
• H/O coffee ground vomitus 2 episode before 10 days
• H/O abdominal pain-
continuous
dull aching
over the epigastrium
not radiating to the back
not aggravated or relieved by food intake.

• No H/O early satiety .

• H/O loss of appetite
• H/O significant weight loss .
• H/O constipation present.
• H/O easy fatiguability present
No H/O Malena.
No H/O mass in the abdomen
No H/O yellowish discoloration of sclera
No H/O cough or haemoptysis
No H/O back pain
No H/O abdominal distension
PAST HISTORY
No H/O peptic ulcer disease in the past
Not a known case of Diabetes mellitus, Bronchial asthma,
Hypertension, Tuberculosis, Coronary artery disease, Thyroid
disorder.

SURGICAL HISTORY
H/O herinal repair before 1 year
PERSONAL HISTORY
• Patient consumes mixed diet, Normal sleep pattern, Normal
bladder habits and constipation
• The patient was a smoker and smoked 10 cigarette per day for
past 15 years.
• The patient is not an alcoholic

FAMILY HISTORY
• No similar complaints among family members
 GENERAL PHYSICAL EXAMINATION

• Patient is conscious ,oriented ,afebrile, poorly built and poorly nourished

• Pallor is present
• No icterus
• No cyanosis
• No clubbing
• No generalised lymphadenopathy
• No pedal edema

SIGNS OF DEHYDRATION:
• Dry tongue and skin turgor is lost
VITALS

• Pulse: 74 beats/min ,measured in radial artery , low volume

• Blood Pressure: 110/70 mmHg measured in right upper arm in sitting

position

• Respiratory Rate: 16 breaths/ min,

• Temperature: 98.6 degree Farenheit

LOCAL EXAMINATION OF THE
ABDOMEN
• After getting informed consent, patient is examined in supine position and exposed
from neck to mid-thigh

INSPECTION
• Abdomen is scaphoid in shape
• Umbilicus is normal in position and inverted .
• Visible gastric peristalsis seen .
• No visible mass is seen.
• No nodules seen around umbilicus
• All quadrants move with respiration
• No dilated veins ,scars ,sinuses present
• No visible pulsations seen
• Hernial orifices are free
• External genitalia are normal
• No fullness in left supraclavicular fossa
• Flanks are free.
PALPATION
• Patient is examined in supine position with hip and knee flexed
• No warmth and tenderness.
• Abdomen is soft, no guarding and rigidity
• A single irregular shaped swelling of size 6×4 cm is located in the umblical
region extending to right hypochondrium

Extent of the swelling:

Superior border: 5cm below the xiphisternum.
Inferior border: 1cm above the umblicus
Left border: 3cm from the midline
Right border: 2cm from the right midclavicular line.
• Surface is irregular
• Margins are ill-defined
• Hard in consistency
• The mass moves with respiration.
• The plane of the swelling is intraperitoneal.
• Transverse mobility present and no vertical mobility.
• Examination of other quadrants Normal
• External genitalia normal
• No palpable left supraclavicular lymph node
PERCUSSSION
• Dull note on percussion over the mass
• Liver span- 13 cm
• No clinical evidence of free fluid

AUSCULTATION
• Normal bowel sounds heard
• Succussion splash heard.

PER RECTAL EXAMINATION - Not done

OTHER SYSTEM EXAMINATION
• Cardiovascular system:S1 and S2 heard, no murmurs

• Respiratory System: Normal vesicular breath sounds heard, no added

sounds

• Central Nervous System: No focal neurological deficit

SUMMARY
A 63 year old male came with non bilious vomiting with partial
digested food particles after > 4 hours of food intake for past 6 months,
significant loss of weight ,loss of appetite , constipation and smoker. On
examination, visible gastric peristalsis is seen and a palpable mass is
present in the umbilical region extending into right hypochondrium of
size 6×4 cm which is irregular in shape , hard in consistency, moves with
respiration, with intrinsic mobility, intraperitoneal, dull note on
percussion and succussion splash heard on auscultation , no free fluid
and normal hepatic span.
DIAGNOSIS
• A case of Gastric outlet obstruction due to
carcinoma of stomach –probably pyloric antral
growth.
INVESTIGATION
Baseline Investigations
• Complete blood count
• Blood grouping and typing
• Bleeding time and clotting time
• Blood sugar
• Serum urea and creatinine
• Chest X-ray
• ECG
• Renal function tests
• Liver function tests
• Specific Investigations
• Serum electrolytes
-Hypochloraemic alkalosis
-Hyponatriemia
-Paradoxical aciduria
-Hypokalemia
-Hypocalcemia
Upper Gastreointestinal Endoscopy
-Direct visualisation of tumour
-Site and extent of tumour
-Biopsy
Diagnostic laparoscopy:-
- To find signs of operability
–To check for liver deposits
–To see for serosal involvement
- To see peritoneal deposits
Metastaic workup
• Ultrasound Abdomen
- Ascites
-Secondaries liver
- pelvic deposits
• CECT Abdomen
-Nodal status
- Ascites
-Secondaries liver
- local infiltration
• Endoscopic Ultrasound(EUS)
-Involvement of layers of stomach
- Nodal status
-Tumour staging
• CT Thorax - if abnormalities in chest X-ray
• Tumor marker
PREPARATION OF THE PATIENT
• Assess nutritional status of the patient.
• Correction of anemia.
• Correction of hypoalbuminemia.
• Correction of electrolyte abnormality
• Gastric decompression by Ryles tube aspiration

TREATMENT
Subtotal Gastrectomy with Roux-en-Y Gastro-jejunostomy with D2 dissection
THANK YOU