<Brief
History> A 77-year-old man was
hospitalized because of exertional dyspnea for 10 days.
Two years before this admission, the patient had subtotal
gastrectomy for gastric cancer at a local hospital with
initial presentation as epigastralgia. Postoperative course
was quite smooth. One month before this admission,
epigastralgia recurred to him. Tarry stool for three times
within one day was also noted. He consulted the local hospital
for fear of cancer recurrence. No active bleeder was told
after upper endoscopy examination except erosion on remnant
stomach. The symptoms improved after medication and
transfusion. Ten days before this admission, progressive
dyspnea on exertion developed. There was no history of chronic
cough, fever, chills, chest pain, orthopnea or paroxysmal
nocturnal dyspnea.
On admission, the temperature was
36.8°C, the pulse was 123, and the respirations were 22. The
blood pressure was 130/ 85 mmHg. Physical examination revealed
pale conjunctivae. The jugular veins were not engorged.
Regular heart beat with tachycardia was noticed on
auscultation. Breath sounds were clear bilaterally. Bowel
sounds were hypoactive, and no mass was palpated. There was no
active lesion over bilateral lung fields in chest radiograph.
The urine was normal. The hemoglobin level was 6.0 g/dl with
MCV of 85.7 fl. Stool occult blood test showed (4+). He
accepted to have upper endoscopy examination again, and a
longitudinal submucosal tumor with ulcerated surface near the
end of afferent loop was found (Fig.
1). Besides, abdominal ultrasonogram showed a 10 x 8 cm
heteroechoic tumor with air trapped inside (Fig.
2). Abdominal CT scan also revealed a 10 cm well-defined
hypovascular tumor with spotty calcification in the pancreatic
region (Fig.
3). There was no dilatation of main pancreatic duct. As
the A-loop biopsy showed spindle cell tumor, the patient
accepted to have operation. Pathology of the surgical specimen
also proved to be a c-kit positive gastrointestinal stromal
tumor (GIST) (Fig.
4
). The postoperative course was
smooth, and the patient received regular follow-up at
outpatient clinic.
<Laboratory
Results>
1. CBC:
|
WBC |
RBC |
Hb |
Hct |
MCV |
Plt |
|
K/μl |
M/μl |
g/dl |
% |
fl |
K/μl |
11/25 |
8.28 |
2.23 |
6.0 |
19.1 |
85.7 |
334 |
11/26 |
7.95 |
2.81 |
7.7 |
24.4 |
86.8 |
324 |
12/2 |
7.18 |
3.58 |
9.6 |
29.9 |
83.5 |
219 | 2. Biochemistry:
|
Alb |
Bil-T |
Bil-D |
AST |
ALT |
gGT |
BUN |
Cre |
Na |
K |
|
g/dl |
mg/dl |
mg/dl |
U/l |
U/l |
U/l |
mg/dl |
mg/dl |
mmol/l |
mmol/l |
11/27 |
3.6 |
0.6 |
0.2 |
28 |
11 |
23 |
15.9 |
1.1 |
139 |
4.7 | 3. Iron Profile:
|
Ferritin |
Iron |
TIBC |
11/25 |
9.92 (ng/ml) |
4 (μg/dl) |
336
(μg/dl) | 4. Tumor markers:
|
CA19-9 |
CEA |
|
U/ml |
ng/ml |
12/3 |
9.77 |
1.0 | <案例分析>此為一個胃癌經亞全胃切除的病患,於門診追蹤第三年發現有上腹痛及黑便的表現。因為之前的胃癌病史,第一線的醫師安排了胃鏡以確認是否有上消化道病灶的存在。但在初次胃鏡檢查時並無發現明確之出血點,僅見胃糜爛
(erosion)於殘胃黏膜。之後發生的用力時呼吸困難,可考慮為原發性心肺疾病或是系統性疾病造成續發性心衰竭的表現。病史上並無發燒、其他相關心衰竭的病程變化或是慢性阻塞性肺病,理學檢查上有頻脈但是沒有頸靜脈脹大、心雜音、不整心律、肺囉音等等。然而結膜檢查較蒼白,加上解黑便的病史,為了代償失血引起的心輸出量提高,應該是造成這個病患呼吸不適的合理解釋。解黑便一般可視為上消化道出血的同義詞,但是需要排除使用鐵劑或其他藥物或色素的影響。不明確性消化道出血(obscure
GI
bleeding)係指在第一次內視鏡檢查沒發現出血點,但是臨床上仍然有反覆或是持續的出血表現,如缺鐵性貧血或黑便等等。有不少學者建議在進行腸道其他部位內視鏡檢查﹝如小腸鏡﹞之前,先重覆第二次的胃鏡檢視,因為仍有高達三成的病灶可被找出來。本病患在進行第二次的胃鏡檢視後,發現之前手術後的腸道盲端(afferent
loop)內有一黏膜下腫瘤,經病理切片暨免疫染色證實為胃腸基質瘤(GIST)。病患接受手術切除的治療後,由於腫瘤大於十公分以上,分類上為高危險度的惡性傾向,所以建議仍需長期在門診追蹤。 |