LSU Internal Medicine Case Conference May 1 st , 2012

1. LSU Internal Medicine Case ConferenceMay 1st, 2012 Courtney Austin, MD PGY-4 LSU Internal Medicine & Pediatrics

2. Chief Complaint “Abdominal Pain for 2 Weeks”

3. HPI • 46 year-old man with significant past medical history of TB (treated in prison with RIPE x 6 months) and GSW (abdomen and RLE >10 years ago) presents to the ED with complaints of nausea and abdominal pain for two weeks. • The patient describes the pain as sharp, stabbing, radiating to the back, and associated with mild nausea but no vomiting. He also states that there are no identified alleviating factors for his pain. • He also complains of early satiety for the past two weeks, with a 15 pound weight loss over the past month.

4. HPI • The patient denies any change in stool consistency, hematochezia, melena, or diarrhea, but does note that his bowel movements are less frequent since the onset of his poor appetite. • He was evaluated for these complaints at Ocshner Main Campus two weeks prior to his presentation, and he was prescribed a course of ciprofloxacin and metronidazole for a presumed diagnosis of gastroenteritis versus small bowel ileus.

5. Past History • Past Medical History: • Tuberculosis, diagnosed in 2005, treated with 6 months of RIPE therapy • Surgical History: • RLE Fasciotomy 2/2 GSW in 2000 • Exploratory Laparatomy, 2000 • Family History: • Maternal Grandmother with Colon Cancer (still living post-resection)-- initially diagnosed in her 60s

6. Past History • Meds: • Recent completion of 10-day course of ciprofloxacin and metronidazole • Denies NSAIDs, Aspirin, and Tylenol use • Allergies: • NKDA

7. Past History • Social History: • Smokes marijuana cigarettes daily • Denies tobacco abuse • Drinks 1-2 6 packs of regular beer per week, no h/o DTs • Denies any IV drug abuse • Has several homemade tattoos from prison • Sexually active with women, last HIV test two years ago that patient self-reports as negative • History of incarceration for one year from 2004 to 2005 • Unemployed

8. Past History • Health Maintenance: • Colonoscopy Not UTD • Influenza, Pneumovax Never Received • TDaP UTD (2006) • PCP None

9. ROS • Endorses: • 15 Pound Weight Loss • Denies: • Fever, Chills, Meningismus, Dysphagia, Epistaxis • Chest Pain, Dyspnea, Diaphoresis, Orthopnea, PND, Syncope • Cough, Wheezes, Hemoptysis • Vomiting, Dysphagia, Diarrhea, Constipation, Melena, BRBPR, Decreased Stool Caliber • Dysuria, Hematuria, Urinary Urgency, Flank Pain, Penile Discharge/Lesions • Easy bruising/bleeding , Recent URI/GI Illness • Anesthesia, Paresis, Paralysis, Dysarthria, Ataxia; additional Paresthesia & Altered Sensory Perception • Denies Recent Travel, Sick Contacts

10. Vital Signs & Physical Exam

11. Vital Signs • Temp97.9OF • Pulse 70 • RR 16 • BP 106/76 • Pulse Ox 100% on RA • BMI 21.3 • Weight 70 kg • Height 180 cm

12. Physical Exam I • General: • AAOx3, NAD, thin male • HEENT: • NCAT, PERRLA, EOMI, Oropharynx clear, no erythema or exudate • Neck: • No LAD, no thyromegaly • Cardiovascular: • Regular rate & rhythm, no murmurs/rubs/gallops

13. Physical Exam II • Pulmonary: • CTA Bilaterally, no wheezes/rhonchi/crackles • Abdomen: • Decreased bowel sounds; diffusely TTP through all four quadrants; no HSM, no masses • Extremity: • 2+ peripheral pulses, no edema, no axillary or inguinal lymphadenopathy • Rectal: • Good tone, no masses, brown stool, Hemoccult® (-)

14. Physical Exam III • Neurologic: • Motor: 5/5 upper and lower extremity, 2+ DTRs • CN: PERRLA, EOMI, symmetrical facial expression, no dysarthria, uvula midline, tongue protrusion midline, normal sensation • Sensory: intact light touch, pain, and proprioception in upper & lower extremities • Cerebellar: Intact heel to shin bilaterally, normal diadochokinesia, no tremor, no dysmetria • Normal plantar reflex bilaterally

15. Laboratory Data Day of Admission

16. Admit Laboratory Data I • WBC 10.3 • Hgb14.3 • Hct43.9 • PLT 221 • MCV 84.3 • RDW 14.5 • Segs70% • Lymphs16% • Monos9%

17. Admit Laboratory Data II • Na 141 • K 3.7 • Cl110 • Bicarbonate 23 • BUN 22 • Creatinine1.08 • GFR >60 • Glucose 109 • Ca++ 8.9 • Mg++1.9 • Phos3

18. Admit Laboratory Data III • Total Protein 6.4 • Total Bilirubin1.2 • Albumin 3.9 • AST 17 • ALT 12 • Alkaline Phosphatase49 • INR 1.2 • Amylase 48 • Lipase 18

19. Admit Laboratory Data IV • U/A • Color Pale • SG1.029 • pH6.5 • ProteinNeg • BloodNeg • Urobilinogen1.0 • Ketones15 • Leukocytes 25 • Micro • WBC0-2 • Bacteria0-2 • SquamEpi2-20

20. Admission KUB

21. Chest X-Ray and KUB Day of Admission

22. Hospital Day 1

23. Initial Management • Bowel Rest, NPO with IV Fluids • Held IV Antibiotics • Symptomatic care with Nexium, Colace

24. Additional Laboratory Data • Hepatitis Panel Negative • HIV Negative • Urine Culture Negative • Urine GC/Chlamydia Negative

25. Hospital Course: Day #4 • Unable to tolerate liquide diet • Attempts to improve nutrition were made with a nasogastric tube, which worsened the patient’s nausea and vomiting. • Repeat abdominal imagining performed 4 days after admission, prompting an interventional radiology and GI consult.

26. Abdominal CT with Contrast

33. Hospital Day #6 • EGD and flexible sigmoidoscopy were done to evaluate the patient’s diffuse stomach thickening that was seen on abdominal imaging.

34. EGD/Colonoscopy Report

35. Esophagitis with slightly irregular Z-line • Nodular-appearing body of the stomach • Multiple biopsies taken • Findings appear consistent with gastric Crohn’s versus infiltrative gastropathy

36. Pathology from EGD

41. Invasive adenocarcinoma, diffuse type. Chronic active gastritis and intestinal metaplasia.

42. Final Diagnosis Stage IV Gastric Adenocarcinoma

43. After Diagnosis • On HD #10, the patient received his diagnosis, and hematology and oncology were consulted to evaluate the patient. • Due to the mainstay of life-saving therapy being surgical resection, surgical oncology was consulted and the patient was discussed at the ILH tumor board. • Careful review of the patient’s imaging with radiology revealed likely carcinomatosis from metastatic disease that spread from his stomach to the celiac plexus and head of the pancreas.

44. After Diagnosis • Surgery to stage the cancer was tentatively planned; however, the patient decided against a surgical staging procedure since it would not palliate his symptoms, and the surgeons were unlikely to perform a successful resection of the cancer. • After another two days in the hospital, the patient went home with hospice.

45. Discharge Follow-Up • Home Hospice • Oncology Clinic

46. Discharge Diagnoses • Stage IV Gastric Adenocarcinoma • Malnutrition • Chronic Nausea

47. Thanks For Your Attention!