Presented by:Sir Salimullah Medical College

37th Batch (Roll: 115-124)

Particulars of the patient

• Name : Md. Monir Hossain

• Age : 18 yrs • Sex : Male

• Marital status : Unmarried • Religion : Muslim

• Occupation : Student, Diploma of computer hardware

• Present Address : Satrauza, Mitford, Dhaka.

• Permanent Address : Ramgonj, Lakkhipur.

• Date of admission : 05/11/2012

• Date of examination : 03/12/2012

Chief Complaints:

1. Pain on the upper mid abdomen for 1½ yrs.

2. Vomiting for 1 year which was exaggerated for the last 1½ months.

History of Present Illness :

According to the statement of the patient, he was free from Above symptoms about 1½ year back. Then he developed pain in the upper mid abdomen which was mild, burning in nature, relieved by taking food and anti-ulcer medications with episodic occurrence.

About one year back he developed vomiting after taking food. Vomiting was non-projectile and once daily at first; later became twice daily, projectile, bitter in taste, contained food particles taken earlier in the day.

History of Present Illness (Cont.) : On consulting the local doctor 8months back, patient

started on anti-ulcer medication (Esomeprazole) and vomiting stopped for 3 months. Then vomiting again started 4 months back, which was exaggerated, about 3-4 times daily, about 1½ months back.

One month back patient noticed swellings that moved about the abdomen after taking meal, from left to right in the upper abdomen. Patient has mild constipation, his bladder habit is normal. Now he has come to this hospital for better management.

History of Past Illness: Patient had frequent dyspepsia about 1½ year

back. Patient is non-diabetic, normotensive, and non-asthmatic. No history of any operation, or significant trauma was given.

Treatment History: Patient was treated with PPI (Esomeprazole)

for about 8 months. No other treatment was administered.

Family History: Nothing contributory was found.

Personal history: No history of smoking or alcohol intake.

Diet habit is normal. Lives in semipaka tin shed house.

Sanitation is satisfactory and drinks supplied water.

Immunization History: Fully immunized as per EPI schedule.

Allergic History: Nothing significant

General Examination1. Appearance : Ill looking

2. Body build : Average

3. Nutrition : Undernourished

4. Decubitus : On choice

5. Pallor : Mild (+)

6. Jaundice : Absent

7. Cyanosis : Absent

8. Clubbing : Present

9. Koilonychia : Absent

10. Leukonychia : Absent

11. Oedema : Absent

12. Dehydration : Absent

13. Pulse : 75 beats/min (Regular)

14. Blood Pressure : 100/75 mm Hg

15. Temperature : Not raised

16. Respiration : 20 breaths /min

17. Hair distribution : Normal male pattern hair distribution

18. Lymph Node : Accessible lymph nodes not palpable

19. Neck Vein : Not engorged

20. Thyroid Gland : Normal

General Examination

Alimentary System ExaminationINSPECTION

1. Shape : Flat

2. Flanks : Not full

3. Umbilicus : Inverted And Central in position

4. Visible vein : Absent

5. Visible Pulsation : Absent

6. Visible peristalsis : Peristalsis is visible in the epigastric region moving from left to right.

7. Scar marks : None

8. Visible swelling : Absent

9. Hernial Orifices : Intact

PALPATIONa) Superficial palpation :

1. Local temperature : Normal

2. Rigidity and muscle guard :Absent

3. Any Pulsation : Absent 

b) Deep palpation and organ palpation :

Tenderness: Absent.

Lump : No lumps felt.

Liver : not palpable

Gall bladder : Not palpable

Spleen : Not palpable

Kidney : Not pulpable

PERCUSSION

a) Percussion note : Tympanatic

b) Shifting dullness : Absent

 

AUSCULTATION

1. Bowel sound : Present & normal

2. Succussion Splash: Present

AUSCULTO-PURCUSSION

Greater curvature of the stomach was normal in position.

PER-RECTAL EXAMINATION :Not done

OTHER SYSTEMIC EXAMINATIONS:

Revealed no other abnormality.

Salient Features 18 yrs old male patient Md. Monir Hossain hailing from

Ramgonj, Lakkhipur was admitted at this hospital with the complaints of burning epigastric pain for 1½ yrs and vomiting for the last 1 year which has worsen since last 1½ months.

According to the statement of the patient, he was reasonably well about 1½ year back. Then he developed pain in the epigastric region which was mild, burning in nature, relieved by taking food and anti-ulcer medications and was episodic in occurrence.

About one year back he developed vomiting after taking food. Vomiting was non-projectile and once daily at first; later became twice daily, projectile, bitter in taste, contained food particles taken earlier in the day. No history of blood in the vomit.

On consulting the local doctor 8months back, patient started on anti-ulcer medication (Esomeprazole) and vomiting stopped for 3 months. Then vomiting again started 4 months back, which was exaggerated, about 3-4 times daily, about 1½ months back.

Salient Features (Cont.)

Patient has good appetite, no fullness of abdomen and no significant weight loss or wasting. No history of melena (black tarry stool). Patient has mild constipation, his bladder habit is normal.

On general examination patient was ill looking, undernourished with mild pallor (+) and clubbing. No accessible lymph nodes were palpable.

On systemic examination patient had visible peristalsis in the epigastric region moving from left to right. No lump was felt. On auscultation, succession splash was heard. All other findings were normal.

Salient Features (Cont.)

DIAGNOSIS

PROVISIONAL DIAGNOSIS : Gastric Outlet Obstruction Due to;

Pyloric stenosis secondary to peptic ulceration.

Differential Diagnosis: Gastric carcinoma (Common) Pancreatic Carcinoma, GIST (Gastro-Intestinal stromal Tumor) Adult Pyloric stenosis (rare), Congenital duodenal webs (rare).

INVESTIGATIONS

Routine Investigations:

CBC : Hb% - 12.1gm/dl

Total RBC count - 4.2 million/µl

Total WBC count - 8,600/cumm

Total platelet Count - 240,000/cumm

ESR : 72 mm in the 1st hour

Serum Electrolyte : Normal (as per report)

Blood sugar : 5.2 mmol/L (Normal)

X-Ray :

Straight x-ray chest AP view on errect posture revealed no abnormality or deformity.

Ultrasonogram:

Normal study, no abnormality was detected.

Diagnostic Investigations

Barium meal X-Ray:

(The report)

Barium meal X-Ray (Cont.) :

Barium meal X-Ray (Cont.) :

(Narrowing)

CT Scan :

Stomach : Appears to be distended in size.

Duodenum : Distal part of descending loop of duodenum not well outlined with contrast – Possibly narrowed (Endoscopy please).

Pancreas : Normal in size, shape, position & tissue density. No evidence of annular pancreas.

Liver : Normal in size with uniform tissue density.

Gall Bladder : Normal in size & shape. Lumen clear.

Billiary Tree : Not dialated.

Spleen : Normal in size & tissue density.

Kidney: Both kidneys are normal in size, shape & excretion of contrast material.

Endoscopy : Oesophagus :

Mucosa contains no lession, lumen appears normal, no varix seen.

Stomach :

Mucosa covering cardia, fundus, body & antrum seem normal. Pylorus is normal.

Duodenum :

The bulb is grossly deformed. An ulcer is seen. The channel is narrowed. The endoscope could be passed into the post-bulbar area with moderate effort.

Comment:

CHRONIC DUODENAL ULCER WITH GASTRIC OUTLET OBSTRUCTION.

Confirmatory Diagnosis

Gastric Outlet Obstruction Due to; Duodenal ulceration & stenosis.

Treatment Patient was treated surgically by performing

a;

SIMPLE GASTRO-JEJUNOSTOMY

Mid line incision on the upper abdomen

STOMACH

Pancreas

Narrowing

Stomach & intestine held by gastro-jejunostomy clump and being sewn togather.

OOPPSSS…This is Embarrassing…

During the operative procedure surgeon found several lymph nodes to be enlarged… Being curious he took a lymph node for biopsy..

Guess what?? The biopsy revealed that the ulcer was in fact a tuberculous ulcer.

Patient had MT test done previously but MT test showed only 5mm of induration on the 3rd day.. So, TB was ruled out initially. But turns out the diagnosis was TB all along..

So, what did we learn from it??

In Bangladesh, EVERYTHING IS TB.. :@