消化内科病案讨论

History of present illness(1):
The patient complained that 2 months ago, he appeared abdominal pain for half a hour without any precipitating factor. It is mid and upper abdominal distending pain, with burning sensation, sour regurgitation, belching, without nausea, vomiting, without melaena, hemafecia, dizziness. In the local hospital, the gastroscopy showed “gastric ulcer”…
Preoperative Exams:
Barium meal Exam: Gastric antrum is stricture, and it bound with gastric wall clearly. Mucosal plicae of gastric antrum are disruption and flat. It can be seen obvious filling defect and double-egded sign. Barium passed it slowly. Result: Occupation lesion in gastric antrum.
K 3.81 mmol/L (3.5-5.0)
Cl 107.2 mmol/L (100-110)
Ca 2.04 mmol/L (2.1-2.7)
Preoperative Exams:
Blood coagulation test: PT 12.0 Sec (11.0-14.8) APTT 32.0 Sec (30.0-45.0) FIB 3.46 g/L (2.0-4.0)
Preoperative Exams:
Chest Radiography: Thorax present barrel-shaped, thickening of lungncreased, rough and disorganization; incongruous shadow in both lungs. Result: 1. Bilateral lungs chronic bronchitis, pulmonary emphysema changing, middle field-lateral band of right lung has calcific shadow;
Marital History and Family History: normal.
Physical Examination (PE):
Temperature 36.6℃
Pulse 82 bpm
Respiration 20 times per minute BP 14.5/8.5 KPa.
Consciousness; skin and sclera are not xanthochromia; bulbar conjunctiva is pale; superficial lymph nodes are not palpated; heart and lungs are normal…
What preparations should be done preoperatively?
Examination before admission:
Blood Routine: RBC 3.25×1012/L, Hb 106 g/L,
plt 237×109/L,
WBC 5.91×109/L,
Case Discussion
General Surgery Department Dr. Hu Jiankun
Patient X X X Male 57 years old No. 913122
Admission:
Aug. 9th, 2004
Chief Complaint: Abdominal pain for 2 months
Intra-operative Finding(2):
5×5×4 cm mass in prepylorus area of gastric antrum, and serosa is involved. The mass is mobile. The caput pancreatic isn’t infiltrated.Superior and infra-pylorus lymph nodes enlarged…
Intra-operative Finding(3): And another 5×5×5 cm mass is palpated in lesser curvature of gastric cardia. Serosa is involved. Left gastric wall and esophagus aren’t infiltrated. Left and right pylorus and lesser curvature of gastric body lymph nodes are enlarged.
ALT 52 IU/L (5-55)
AST 37 IU/L (5-46)
A/A 0.71
Alb 33.9 g/L (35-55) A/G 1.73 (1.2-2.5)
GLU 5.00 mmol/L (3.9-5.9)
GGT 4 IU/L (6-46)
CK 34 IU/L (19-226)
Na 142.8 mmol/L (135-145)
Examination before admission: Gastroscopy(2):
They are with muscus and peripheral mucosa is hyperemic And red swollen. And they are easily hemorrhaged. Lesion led cavity of gastric antrum to deformation, stricture and pylorus to malformed, poor switch.
Tumor marker:
CEA 43.52 ng/ml (0-3.4)
Preoperative Exams: Routine test of Pretransfusion: Negative ECG: Normal B-ultrasound: Negative Lungs function: Normal
Resected specimen It can be seen that blood vessels of gastric antrum wall and pylorus anterior layer in anatomical specimen have been thicken. The central have 3×3×1 cm ulcer. It penetrated total layers and involved serosa. Separating lymph nodes from lower pylorus…
Questions:
1. what is the most possible diagnosis of this patient?
2. which methods should be done to verify the diagnosis?
3.
what are the surgery indications for
Physical Examination (PE):
Total abdomen is soft without tenderness, rebound tenderness and muscular tension. There are no mass palpated in total abdomen. Splashing sound is negative. Liver and spleen are not palpated. Murphy sign is negative. Both lower limbs are not swollen.
1 year ago, he was ill with “pneumonia”.
Denying hepatitis and tuberculosis.
Others were normal.
Personnel History: Smoking 30 years, 10-20/Day; No
drinking.
N% 64.6%, Pathologic exam:
LY% 29.9%
Gastric antrum and fundus poor differentiated adenocarcinoma
(more signer-ring cell carcinoma)
Preoperative Exams:
Biochemistry:
2. Shadow of heart is normal.
Preoperative Treatments:
Routine of Surgery Nursing; Fasting; Gastrointestinal decompression; Using Ofloxacin and Metronidazole.
gastric ulcer?
4.
which surgery should be performed for
this patient and why?
Examination before admission: Gastroscopy(1):