Manal Mubarak AlQuaimi R1 KFMC KFU 09/01/2014 Case presentation Manal Mubarak AlQuaimi R1 KFMC KFU 09/01/2014

التواريخ

Chief Complaint Epigastric pain and nausea of 4 weeks duration

History of Presented Ilness 27 years old Philippines lady without any past medical history has developed epigastric pain over last 4 weeks. The pain was gradually started , compressing in nature , mild to moderate in severity with no radiation or shifting of the pain , not related to meals with no known aggrevating factors and was mildly relived by spasmolytic and analgesics .

History of Presented Ilness Associated with Nausea which was intermittent , with no diurnal variation No history of anorexia No history of vomiting No history of recent Wight loss

No history of change of urinary habits No history of change of bowel habits No Melena , No hematemesis No History of change in Scleral color And she didn’t report any history of fever

Systemic review Unremarkable

Drug and Allergy History : No known food or drugs allergy , she takes OCP “ oral contraceptive bells “ during last 3 years\ He had never drunk or smoked Past Medical History : Negative for any chronic medical illnesses Past Surgical History : Negative

Family History : No chronic diseases runs in her family Social History Working nurse , physically active good socioeconomic status Married

Physical Examination The patient was in good health, ambulation , not on pain or distress not pale or jaundiced she was afebrile, and her vital signs was within normal range Heart rate :88 bpm Temperature : 36.7 C Blood pressure : 106/78 mmHg Respiratory rate : 18 bpm

Physical Examination - Flat abdomen , No obvious masses No skin changes no dilated veins No scar soft and non-tender, no organomegaly Palpable not tender mass vs fullness in epigastric “ 2 inch below the xiphoid to the left “about 4 by 5 cm regular edges, soft to firm , non-pulsatile dull on precussion Respiratory and vascular systems were unremarkable

Laboratory Hematological examination and biochemical tests were within normal limits

CBC : WBC:8.64 10e9/L HGB:12.80 g/dl Hematocrit :36.70 % Platelet:352.00 10e9/L

Coagulation profile : PT 12.1 sec INR 0.9 APTT 37.1 sec

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Urea breath test   for  H.  Pylori  infection

Imaging studies 10th of November 2013 : U/S done a  well- defined  lesion  in  relation  to  the  distal  stomach  sho wing  central  necrosis  and  well  defined  margins  wit h  tiny  echogenic  peripheral  foci  probably  calcificatio n;  it  measures  approximately  3.9  x  3.1  cm  and  sh ows  minimal  vascularity  on  Doppler  imaging  in  the  periphery.; pancreas, liver and spleen were normal.

u/s

Imaging studies 11th of November 2013 : CT with oral and IV contrast : with contrast showed Involving  the  pylorus  of  the  stomach,  there  is  a  ro und  well- defined  3.6  x  3.4  cm  hypodense  lesion  which  is  pr obably  submucosal.    There  is  no  associated  lymph adenopathy.    There  is  no  perigastric  extension.  The   peritoneum  is  fine. The  pancreas,  adrenals,  spleen  and  both  kidneys  a re  within  normal  limits.

Imaging studies 12th of November 2013 : EUS with FNA : n intramural ( subepithelial ) lesion was found in the antrum of the stomach . the lesion was appeared to originate from within the muscularis properia ( layer 4 ) Tiussue was obtained from this exam through FNA and resulted in ( begin gastric epithelial cell and was negative for malignancy ) a decisionwas made to proceed with surgery then the patient admitted on 23rd of Nov. repeated clinical examination was the same and all Hematological examination and biochemical tests were within normal limits

FNA :

Based on the Radiologic , clinical and pathologic information a preoperative diagnosis of gastrointestinal stromal tumor (GIST) was strongly favored and patient was taken to theater on 24th of Nov., a submucosal tumor around 3 by 3.5 cm located in pyloric area, with a distal limit of 10 mm from the pylorus was found. The underlying mucosa was intact. The surgeon considered the tumor to be a gastrointestinal stromal tumor (GIST) and a distal gastrectomy with Billroth II anastomosis was carried out.

The postoperative course was uneventful and the patient was discharged 5 days after surgery. He has remained free of symptoms and she back to her work after 3 weeks in good condition

Histopathology Gross examination of the resected specimen showed a well limited mass with normal overlying mucosa, located on the anterior wall of the pyloric antrum Microscopic examination of the lesion showed Sections reveal islands of pancreatic acini and ducts in the muscularis propria of the stomach. Several dilated ducts are seen extending through all the layers of muscularis propria. Surrounding the ducts are layers of fibroblastic reaction and scant mixed inflammatory infiltrate. Other areas show more extensive fibroinflammatory reaction admixed with histiocytes and few aggregates of giant cells. No evidence of malignancy is seen.   Immunostains was performed : Cytokeratin 7 : positive in the pancreatic tissue and ducts CA19-9 : positive in the pancreatic tissue and ducts CD117,CD30 ,chromogranin , ER,PR,CDX2,CK20 all was negative

Notes