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| Case of the Week Tuesday8/12/2005 |
Presented by Dr. Mohamed Mohi.
Click here to download a power point presentation for the case.
Staff round presentation
Unit Members:
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Professor Dr.Zakaria Salama
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Assist. Professor Dr.Rabab Fouad.
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Dr.Salwa Mokhtar.
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Dr.Ahmed Salama.
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Dr.Ahmad Nabil.
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Dr.Samar Kamal.
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Dr.Basel Ebeid.
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Dr.Manal kamel.
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Dr.Mohamed El Menasy.
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Dr.Atef Gamal El Din.
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Dr.Basem Amin.
Personal history:
A female patient, B. M. Ammar, 38 years old, married and a mother of 3, the youngest is 5 years old.
She is a teacher. She was born and still living in Cairo.
There are no special habits of medical importance, and no history of contact with canal water.
Menstrual cycles are regular, with no history of use of contraceptive pills or injections.
Complaint:
Abdominal pain of 4 years duration.
Present history:
The condition started 4 years ago by attacks of pain
Epigastric, periumbilical & subumbilical, with no special radiation.
Colicky in nature.
The onset of pain was rather acute, with no precipitating factors (not related to meals, menses, exercise, or psychological stress).
She had used an IUD 3 years ago and it was removed one year ago on the assumption that it is the cause of pain, but the pain persisted after removing the IUD.
The attacks were infrequent, recurring once every 2 to 3 months, and lasted for variable durations (few hours).
The attacks were associated with Constipation; one motion hard stools/day (previously was 2-3 motions/day), but not associated with GI bleeding, vomiting, diarrhea, changes of the urine color, fever, weight loss, or anorectal complaint.
Relieved by spasmolytic injections & sometimes relieved by defecation, and hot fomentations.
During the last 2 months , the attacks became rather frequent, and severe, sometimes associated with vomiting ( 3 attacks), but there was no absolute constipation (she passes stools and flatus) .
She sought medical advice several times,
Once she had abdominal ultrasonography that showed no abnormalities,
Once she was admitted to ER, and was seen by a surgeon, who excluded acute abdomen particularly appendicitis, and she was given antispasmodic injections.
The patient was discovered to have diabetes one year ago (with no manifestations of D.M.), and was controlled on oral hypoglycemics within this year.
No symptoms of cardiopulmonary, genitourinary, neurological, musculoskeletal or skin diseases.
No symptoms suggestive of chronic liver disease.
No manifestations of TB toxemia.
Past history:
She is not known to be hypertensive.
She had tonsillectomy.
No history of blood transfusion.
No history of jaundice.
No history of TB.
Family history:
No similar conditions in the family.
Negative consanguinity
From the history:
Examination:
General examination:
The patient is cooperative, lying comfortably in bed, she looks obese (Weight: 102 kg.).
Vital signs:
Bp: 130/70.
Pulse: 80/min,normal character.
Temp.: 37°C all through the hospital stay.
Head & neck:
No pallor, cyanosis or jaundice.
No oral ulcers or pigmentations.
Neck veins are not congested.
No LN, parotid or thyroid enlargement.
Upper & lower limbs:
No clubbing.
No LN enlargement.
No lower limb edema.
Skin examination:
No stigmata of chronic liver disease.
No manifestations of vitamin deficiency or bleeding tendency.
There is facial acne.
Chest and heart examination: Clinically free.
Neurological and musculoskeletal examination: Clinically free
Abdominal examination:
Back, external genitalia and PR examination: Free.
As a conclusion:
A 38 years old female with
colicky abdominal pain, 4 years duration
± constipation.
± vomiting.
HSM.
No diarrhea, fever, weight loss or GI bleeding.
Investigations
CBC (repeated)
Liver biochemical profile:
Blood sugar level on treatment
Fasting blood sugar: 120 mg/dl
Postprandial blood sugar: 178 mg/dl.
Hb A 1C: 3% ( Normal < 7 %)
Hepatitis markers:
HBsAg: Negative.
HBsAb: Negative.
HB core total: Negative.
HCV Ab: Negative.
Lipid profile:
Cholesterol: 188 mg/dl. (N: 50-200).
TGs: 132 mg/dl. (N: 0-147).
Renal Functions:
Electrolytes:
Abdominal ultrasound
Liver:
Enlarged mainly the right lobe.
Uniform bright (fatty) echo pattern.
Gall bladder:
Pancreas: No gross abnormality.
The mass is seen in lower abdomen & pelvis to the right and above the uterus.
It does not look to be of gynecological origin...
At the distal ileal loops somewhat away from the ileocecal region. with some small nearby intussusception.
It is about 4X4 cm spherical hypoechoic mass.
Conclusion:
Gynaecological & transvaginal US :
Revealed normal uterus and ovaries, and the mass is not related to these organs.
CT scan
abdomen & pelvis:
CT scan abdomen and pelvis with oral & IV contrast:
A Soft tissue density mass is seen as filling inside the terminal ileum, with oral contrast media around, with no wall invasion, no ascites and no lymphadenopathy.
Fatty hepatomegaly and mild splenomegaly.
Normal other abdominal and pelvic organs.
Tumor markers
CEA: 2.5 ( Normal 5 ng / ml).
CA19.9: 15.32 ( Normal 37 ng / ml).
B2 microglobulin: 1900 (N. up to 1150 ug / l
Siginificant level > 4000).
BMFT:
BMFT
Normal appearance of the small bowel down to the ileum.
A mass 4X4 cm in the terminal ileum about 25 cm from the ileocecal valve is seen related to the wall of bowel and mostly benign in nature.
Colonoscopy and ileoscopy
Full colonoscopic examination was done up to the cecum revealed:-
External piles.
No other mucosal abnormalities detected throughout the whole segments of colon.
Examination of the ileum revealed :
A hard non cystic mobile mass at about 25 cm. from the ileocecal valve, rounded, with uneven surface, intact overlying mucosa, and obstructing the lumen.
Biopsies were taken.
Pathology:
The endoscopic biopsy revealed a non conclusive specimen.
Upper GI endoscopy:
Normal apart from mild antral gastritis.
Then the patient was referred to surgery..
Laparoscopy
Laparoscopy was done first and revealed :
Adhesions at the right upper abdomen near the liver, and exploration revealed no pathology.
Fatty liver, with no evidence of cirrhosis and a liver biopsy was taken.
An intussusception was seen at the terminal ileum at about 25 cm from the ileocecal valve with a mass inside.
No extension to mesentry and no LN involvement.
Laparotomy was decided:
Resection of a part of the terminal ileum containing the mass was done, with anastomosis of the intestinal loops.
Pathology of the resected specimen revealed:
Grossly:
An intestinal segment (terminal ileum) 19 cm.
On opening, the antimesenteric border shows a submucosal mass; 5 X 3 cm, rubbery in consistency.
Cut section shows tan colored healthy tissues.
Microscopy:
Proliferated spindle & epithelioid cells with bland looking nuclei, showing inconspicuous atypia.
Background is moderately vascularized & showed scattered inflammatory cells.
Free surgical margins.
Conclusion:
Gastrointestinal stromal tumour (GIST)
Liver:
Macrovesicular steatosis affecting 10 -15 % of hepatocytes.
Follow up of the patient one month after the operation..
Thank you
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