# Clinical Cases: Gastric Surgery

## Case 1: Perforated Peptic Ulcer Disease

### Patient Demographics
- **Age:** 45 years
- **Sex:** Male
- **Occupation:** Restaurant manager

### Chief Complaint
"I have sudden severe pain in my stomach that started 3 hours ago."

### History of Present Illness
The patient presents to the emergency department with acute onset of severe epigastric pain that began suddenly while at work. He describes the pain as "the worst pain of my life," sharp, and radiating to his back. He has been unable to find a comfortable position. He had one episode of non-bloody emesis. He reports a history of epigastric burning for several months, worse with stress and coffee, which he has been self-treating with antacids. He admits to taking ibuprofen frequently for chronic knee pain.

### Past Medical History
- Chronic knee pain (old sports injury)
- No prior surgeries
- No known H. pylori infection

### Medications
- Ibuprofen 600 mg 2-3 times daily
- Occasional over-the-counter antacids

### Social History
- Smokes 1 pack per day for 20 years
- Heavy coffee consumption (5-6 cups daily)
- Social alcohol (3-4 drinks on weekends)
- High-stress job

### Physical Examination
- **Vitals:** BP 102/68 mmHg, HR 112 bpm, RR 22/min, Temp 37.6°C, SpO2 97%
- **General:** Middle-aged male in severe distress, lying motionless, knees drawn up
- **Abdomen:**
  - Inspection: Not moving with respiration, flat
  - Palpation: Board-like rigidity, diffuse tenderness
  - Percussion: Absent liver dullness (Chilaiditi sign variant - suggests free air)
  - Bowel sounds: Absent

### Laboratory Results
- WBC: 15,800/μL
- Hemoglobin: 14.2 g/dL
- Creatinine: 1.4 mg/dL
- Lactate: 3.2 mmol/L
- Amylase/Lipase: Normal

### Imaging
**Upright Chest X-ray:**
- Free air under the diaphragm bilaterally

**CT Abdomen/Pelvis (limited due to clinical urgency):**
- Large pneumoperitoneum
- Free fluid in the abdomen
- Perforation site appears to be anterior duodenum/prepyloric region

### Diagnosis
Perforated peptic ulcer with peritonitis

### Resuscitation
- Large-bore IV access x 2
- Aggressive fluid resuscitation
- Nasogastric tube decompression
- Foley catheter
- IV antibiotics (piperacillin-tazobactam)
- IV PPI (pantoprazole bolus + infusion)

### Operative Management
Emergent exploratory laparotomy:
- Findings: 8 mm perforation of anterior duodenum with surrounding inflammation
- Procedure: Graham patch repair using omental patch
- Thorough peritoneal lavage
- No evidence of malignancy

### Postoperative Management
- ICU admission for 24 hours
- NPO, NGT to suction
- IV PPI continued
- Antibiotics continued for 5 days
- H. pylori testing: Positive (stool antigen)
- Triple therapy for H. pylori initiated when able to take PO

### Postoperative Course
- NGT removed POD 3
- Diet advanced slowly
- Discharged POD 5 on PPI and H. pylori eradication therapy
- Strict NSAID avoidance counseled
- Smoking cessation strongly recommended

### Follow-up
- H. pylori eradication confirmed at 6 weeks
- EGD at 8 weeks: Healed ulcer bed, no residual ulcer
- Continue PPI for 8 weeks total
- Transitioned to H2 blocker for maintenance

### Teaching Points
1. NSAIDs and H. pylori are the two major causes of peptic ulcer disease
2. Free air on imaging indicates perforated hollow viscus
3. Perforated PUD is a surgical emergency
4. Graham patch is the standard repair for perforated duodenal ulcer
5. H. pylori testing and treatment essential after repair
6. NSAID cessation critical to prevent recurrence

### Clinical Image
![Perforated Ulcer Imaging](case_01_image.jpg)

**Image Description:** Upright chest X-ray demonstrating free air under the diaphragm (pneumoperitoneum), a classic finding in perforated peptic ulcer. The crescentic lucency between the liver and right hemidiaphragm indicates intraperitoneal free air.

**Attribution:** Image from Wikimedia Commons, Category:Pneumoperitoneum. Source: https://commons.wikimedia.org/wiki/Category:Peptic_ulcers

---

## Case 2: Gastric Adenocarcinoma

### Patient Demographics
- **Age:** 68 years
- **Sex:** Male
- **Occupation:** Retired factory worker

### Chief Complaint
"I've lost my appetite and have been losing weight for the past 3 months."

### History of Present Illness
The patient presents with a 3-month history of progressive anorexia, early satiety, and unintentional weight loss of 10 kg. He reports vague epigastric discomfort, worse after eating. He has had intermittent nausea but no vomiting. He noticed his stools have been darker recently. He denies dysphagia or odynophagia. He has a history of chronic atrophic gastritis diagnosed years ago.

### Past Medical History
- Chronic atrophic gastritis (diagnosed 15 years ago on biopsy)
- H. pylori infection (treated, but compliance unknown)
- Hypertension
- Type 2 diabetes

### Family History
- Father died of "stomach cancer" at age 72
- Mother died of stroke

### Social History
- Former smoker (30 pack-years, quit 10 years ago)
- Minimal alcohol use
- First-generation immigrant from East Asia

### Physical Examination
- **Vitals:** BP 134/78 mmHg, HR 82 bpm
- **General:** Thin, cachectic male
- **Abdomen:**
  - Soft, mild epigastric tenderness
  - No palpable mass
  - No hepatomegaly
- **Lymph nodes:** Left supraclavicular node palpable (Virchow's node - concerning)
- **Rectal exam:** Guaiac positive stool

### Laboratory Results
- Hemoglobin: 9.8 g/dL (microcytic anemia)
- MCV: 72 fL
- Iron studies: Consistent with iron deficiency
- Albumin: 3.0 g/dL
- CEA: 12.4 ng/mL (elevated)
- CA 19-9: 85 U/mL (elevated)

### Diagnostic Workup

**Upper Endoscopy:**
- Large ulcerated mass in the gastric body along lesser curvature
- Approximately 5 cm in size
- Friable, with active bleeding
- Multiple biopsies taken

**Biopsy Result:**
- Invasive adenocarcinoma, intestinal type (Lauren classification)
- HER2: Negative
- MSI status: Stable

**Endoscopic Ultrasound:**
- Tumor invades through muscularis propria (T3)
- Several perigastric lymph nodes

**CT Chest/Abdomen/Pelvis:**
- Gastric mass with perigastric lymphadenopathy
- Suspicious left supraclavicular lymph node (1.5 cm)
- No liver metastases
- No ascites

**PET-CT:**
- FDG-avid gastric mass
- FDG-avid perigastric and left supraclavicular nodes
- No other distant disease

**FNA of Supraclavicular Node:**
- Metastatic adenocarcinoma consistent with gastric primary

### Clinical Stage
cT3N+M1 (Stage IV - due to Virchow's node)

### Multidisciplinary Tumor Board
- Stage IV gastric cancer (M1 due to distant nodal disease)
- Not candidate for curative resection
- Palliative systemic therapy recommended
- Consider palliative measures if bleeding or obstruction

### Treatment Plan
- Palliative chemotherapy: FOLFOX regimen
- Nutritional support
- Iron replacement for anemia
- Goals of care discussion with patient and family

### Palliative Considerations
- Pain management
- Nutritional support (consider feeding tube if obstruction develops)
- Consideration of palliative gastrectomy or stenting if symptomatic obstruction
- Hospice referral when appropriate

### Teaching Points
1. Gastric cancer often presents at advanced stage with nonspecific symptoms
2. Risk factors: H. pylori, atrophic gastritis, smoking, family history, Asian ethnicity
3. Left supraclavicular node (Virchow's node) indicates advanced disease
4. Complete staging essential before treatment planning
5. Curative surgery only for localized disease
6. Multimodal treatment for resectable disease; palliative chemo for Stage IV

### Clinical Image
![Gastric Cancer Endoscopy](case_02_image.jpg)

**Image Description:** Endoscopic image demonstrating a large ulcerated gastric mass along the lesser curvature. The irregular, raised borders with central ulceration and friable tissue are characteristic features of gastric adenocarcinoma.

**Attribution:** Image from Wikimedia Commons, Category:Gastric ulcers. Source: https://commons.wikimedia.org/wiki/Category:Gastric_ulcers

---

## Case 3: Gastrointestinal Stromal Tumor (GIST)

### Patient Demographics
- **Age:** 56 years
- **Sex:** Female
- **Occupation:** Bank manager

### Chief Complaint
"I was told I have a mass in my stomach found on a CT scan."

### History of Present Illness
The patient was recently evaluated for vague abdominal discomfort and bloating. An outpatient CT scan revealed an incidental gastric mass. She reports mild, intermittent epigastric fullness but no significant pain. She denies nausea, vomiting, weight loss, or GI bleeding. Her symptoms have been stable for several months. She has no history of peptic ulcer disease.

### Past Medical History
- Hyperlipidemia
- Anxiety
- No prior surgeries

### Medications
- Atorvastatin 20 mg daily
- Sertraline 50 mg daily

### Physical Examination
- **Vitals:** Normal
- **General:** Well-appearing woman, normal body habitus
- **Abdomen:** Soft, non-tender, no palpable masses
- **No lymphadenopathy**

### Diagnostic Workup

**CT Abdomen/Pelvis:**
- 4.5 cm well-circumscribed, enhancing mass arising from the greater curvature of the stomach
- Exophytic growth pattern
- No surrounding invasion
- No liver metastases or lymphadenopathy

**Upper Endoscopy:**
- Submucosal mass in the gastric body with normal overlying mucosa
- Smooth, round protrusion into the lumen
- "Pillow sign" positive (compressible)
- Mucosa intact - not biopsied

**Endoscopic Ultrasound (EUS):**
- 4.3 cm hypoechoic mass arising from the fourth layer (muscularis propria)
- Homogeneous internal appearance
- No cystic areas or necrosis
- Features consistent with GIST
- EUS-guided FNA performed

**FNA Results:**
- Spindle cell neoplasm
- CD117 (c-KIT): Positive
- DOG1: Positive
- Consistent with gastrointestinal stromal tumor (GIST)

### Diagnosis
Gastric GIST, 4.5 cm

### Risk Stratification
Using Miettinen criteria for gastric GIST:
- Size: 4.5 cm (>2 cm, ≤5 cm)
- Mitotic rate: To be determined on final pathology
- Location: Stomach (favorable)
- Estimated recurrence risk: Low to intermediate

### Surgical Planning
- Complete surgical resection indicated
- Goal: R0 resection with negative margins
- Lymphadenectomy not required (GISTs rarely metastasize to lymph nodes)
- Wedge resection vs. limited gastrectomy depending on location

### Operative Procedure
Laparoscopic wedge resection of gastric GIST:
- Mass identified on greater curvature
- Adequate margins around tumor
- Wedge resection using laparoscopic staplers
- Tumor removed in endoscopic retrieval bag (avoid rupture)
- No spillage

### Final Pathology
- GIST, 4.5 cm
- Spindle cell type
- Mitotic rate: 3/50 HPF (low)
- Margins: Negative (R0)
- CD117 positive, DOG1 positive
- Mutation analysis: KIT exon 11 mutation

### Risk Assessment (Post-resection)
- Modified NIH criteria: Low risk
- Recurrence risk: <5% at 5 years

### Adjuvant Therapy Decision
- Given low-risk classification, adjuvant imatinib NOT recommended
- Close surveillance recommended

### Surveillance Plan
- CT abdomen/pelvis every 6 months for 3 years, then annually for 5 years
- No role for routine endoscopy unless symptoms

### Teaching Points
1. GISTs arise from interstitial cells of Cajal
2. Most common mesenchymal tumor of the GI tract
3. c-KIT (CD117) and DOG1 are diagnostic markers
4. Risk stratification based on size, mitotic rate, and location
5. Surgery is primary treatment; lymphadenectomy not needed
6. Imatinib (tyrosine kinase inhibitor) for high-risk or metastatic disease
7. Avoid tumor rupture during surgery (seeds peritoneum)

### Clinical Image
![GIST EUS Image](case_03_image.jpg)

**Image Description:** Endoscopic ultrasound image demonstrating a well-circumscribed, hypoechoic mass arising from the fourth layer (muscularis propria) of the gastric wall, characteristic of a gastrointestinal stromal tumor (GIST).

**Attribution:** Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Gastroenterology