5. History of Present Illness
• 5 months PTC
Colicky generalized abdominal pain with PS of 5/10 spontaneously resolves
without any medications taken,
(+) Anorexia
(+) Weight loss (~15kg within 5months)
(-) Jaundice, (-) steatorrhea
(-) Melena , (-) fever
No consultation done
6. History of Present Illness
• Interim still with said symptoms no consult done until
5 days PTC
(+) Vomiting of previously ingested food
(+) Epigastric pain
Patient consulted a private physician Pantoprazole and
Metoclopramide but no relief
Few hours PTC patient had 7 episodes of billous vomiting
Persistence of s/sx prompted consult at the ER and was subsequently
admitted.
7. Review of Systems
• (+) Generalized body weakness, (+) Weight loss – Approximately
15kgs
• HEENT: no icteresia no headache, no vertigo, no sore throat
• CVS: no chest pain, no palpitations
• Respiratory: no DOB, no cough
• GIT: no constipation, no diarrhea, no decrease in caliber of stools, no
melena
8. Past Medical History
• Past Medical History
(-)Hypertension
(-)DM
(-)Cancer
(-) PTB
• Family History
(-) Hypertension
(-) DM
(-) Malignancy
9. Past Medical History
• Personal and Social
History
Smoker 20 years pack smoker
Occasional Alcoholic drinker
• Denies illicit drug use
• No history of surgery
11. Physical Examination upon admission
• Flabby, NABS, soft, non tender abdomen (-) murphy’s, direct
epigastric tenderness, (-) palpable mass
• DRE: Non collapsed bowel wall, no mass palpated
• Grossly normal extremities, no bipedal edema, no cyanosis,no pallor,
no jaundice
12.
13.
14. Laboratory tests upon admission
Blood Chem
Bun 26.03
Crea 212.85
EGFR 24
SGOT 141.55 (3x elevated)
SGPT 196.98 (4x elevated)
Na 128.0
K 3.80
Mg 1.30
CBC
Hgb 16.2
HCT 47.7
WBC 19.32
Neu 92.0
Platelet 419
15. Laboratory tests upon admission
Amylase 99.4
Lipase 46.5
Total protein 78.07
Albumin 42.21
Globulin 35.16
A/G ratio 1: 1.18
16. Imaging upon admission
Chest Xray
PTB both Upper lobes with cicatricial atelectasis in right upper lobe
Scout film of the ABDOMEN UPRIGHT AND SUPINE:
Unremarkable
WAB UTZ:
Chronic Acalculous cholecystitis with Adenomyomatosis
17. Salient Features
Subjective Objective
• Smoker 15 pack years
• Alcoholic drinker
• Vomiting
• Weight loss
• Epigastric Pain
• 80 years old
• Male
• BMI-16.23
• Direct Epigastric, RUQ
tenderness
18. Initial impression
• Proximal Gut Obstruction probably sec to Gastric Mass VS GITB
• Acalculous Cholecystitis
• Electrolyte Imbalance secondary to GI losses
• AKI probably secondary to Dehydration
• PTB treatment complete (2018)
19. Initial management
• NPO
• NGT insertion
• Correction of Dehydration
• Correction of Electrolyte Imbalance
• Diagnostics
• WAB CT with triple contrast once Nephro Cleared
• Nutritional build-up
• Diet Plan: 25 to 30kcal/kg/day Started at 1000kcal TPN slowly progress
20. IMAGING
WAB CT SCAN
There is an ill-defined heterogeneous predominantly hypodense
mass in the junction of the pancreatic body and tail measuring 2.6
cm x 3.3 cm x 2.4 cm (AP x T x CC).
21. WAB CT SCAN
This appears to abut the adjacent jejunum with indistinct
cleavage plane; resultant dilatation of the proximal jejunum and
duodenum is seen.
22. WAB CT SCAN
Encasement of the adjacent splenic artery is
noted. Pancreatic duct is not dilated.
A well-defined non-enhancing hypodense mass
is seen in the junction of the first and second
part of the duodenum measuring 3.9 cm x 3.1
cm x 3.5 cm
23. Imaging
• MRI
• The liver is not enlarged with homogeneous parenchymal and capsular contour.
No enhancing hepatic lesions seen.
• The gallbladder is physiologically distended with no demonstrable filling defect
(dark signal) on T2WI image. Its wall is not thickened.
• There is a non-enhancing ill-marginated T1WI and T2WI hypointense mass along
the junction of the pancreatic tail and body measuring approximately 2.8 cm x
2.9 cm x 3.2 cm (CC x AP x W) exhibiting restricted diffusion on DWI. The inferior
border of the lesion is indistinct from the fourth part of the duodenum, which
appears to have circumferential wall thickening. Encasement of the splenic artery
is noted.
• There is apparent wall thickening in the antropyloric region.
24. EGD
• Esophagus –NGT was noted with mucosal erosions
• GE Junction –Mucosal breaks >5mm confined to
folds noted at the 36cm level from incisors
• Cardia –edematous and hyperemic mucosa with
regular vascular pattern. Cardia is loosely hugging
the shaft of the scope
25. EGD
• Fundus – edematous and hyperemic mucosa with regular vascular
pattern. Pool of bile fluid noted
• Body – edematous and hyperemic mucosa with regular vascular
pattern. Pool of bile fluid noted. Mucosal biopsy for H. Pylori done
• Antrum – edematous and hyperemic mucosa with regular vascular
pattern. Pool of bile fluid noted. Mucosal biopsy for H. Pylori done
• Pylorus – Pyloric ring was incompetent
• Duodenum – Pool of bile noted at the 3rd to 4th portion of duodenum.
Ampulla of vater was identified and appear normal. No masses nor
irregular vascular pattern seen
26. Endoscopic Diagnosis
• Distal Erosive Esophagitis, LA Grade B; Hiatal Hernia; Hyperimic
Pangastritis S/P Biopsy – H. Pylori Negative; Bile Reflux
27. Laboratory Tests
TUMOR MARKERS
CA 19-9 >500 (NV 0 – 37
U/mL)
CBC
Hgb 13
HCT 38.7
WBC 7.0
Neu 70
Platelet 268
Blood Chem
Bun 10
Crea 92
SGOT 55
SGPT 116
Na 142
K 3.80
Mg 1.09
