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Gastric Adenocarcinoma in a Young Nigerian – A Case Report

Oguntoye Oluwatosin Oluwagbenga1, Yusuf Musah1, Olowoyo Paul1, Erinomo Olagoke2, Omoseebi Oladipo2, Soje Michael Osisiogu1, Oguntoye Oluwafunmilayo Adenike3, Fatudimu Oluwafemi4

1 Department of Internal Medicine, Federal Teaching Hospital Ido-Ekiti and Afe Babalola University Ado-Ekiti, Nigeria;
2 Department of Morbid Anatomy, Federal Teaching Hospital Ido-Ekiti and Afe Babalola University Ado-Ekiti, Nigeria;
3 Department of Internal Medicine, Federal Teaching Hospital Ido-Ekiti, Nigeria;
4 Department of Surgery, Federal Teaching Hospital Ido-Ekiti and Afe Babalola University Ado-Ekiti, Nigeria.

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Oguntoye Oluwatosin Oluwagbenga. MBBS (Ibadan), FWACP(Gastroenterol), Lecturer 1 and Consultant Physician / Gastroenterologist and Hepatologist, Department of Internal Medicine, Federal Teaching Hospital Ido-Ekiti and Afe Babalola University Ado-Ekiti, Ekiti State, Nigeria.
Email: proflast@yahoo.com
Telephone: +2348086638538

Received: February 27, 2020
Revised: March 20, 2020
Accepted: March 26, 2020
Published online: April 21, 2020

ABSTRACT

Gastric adenocarcinoma is uncommon among young Nigerians. We present Mrs O.V. a 41year old Nigerian who presented with one year history of recurrent epigastric pain that was peppery/burning in nature, non-radiating, aggravated by eating and temporarily relieved with the use of antacids. There is associated progressive weight loss and secondary amenorrhea since the onset of her illness. She started vomiting two weeks prior to presentation which was non-projectile, containing both recently ingested meals and partially digested stale food substances, vomitus was non-bilous. Episodes of vomiting is usually preceded by abdominal bloating or feeling of indigestion. Clinical examination revealed a chronically ill-looking young woman with a positive succussion splash on abdominal examination. Examination of the other systems was normal. Provisional diagnosis was suspected Chronic Gastric Antral Ulcer complicated by Gastric Outlet Obstruction to rule out Gastric Antral Adenocarcinoma. Abdominal ultrasound and CT scans showed features consistent with Gastric Outlet Obstruction. Upper GI Endoscopy revealed Gastric Antral Adenocarcinoma with Duodenal extension and Chronic Duodenal Ulcer complicated by Gastric Outlet Obstruction. Histology showed well differentiated Gastric Antral Adenocarcinoma. She had a Bilroth II procedure(Partial Gastrectomy and Gastro-Jejunostomy)and was commenced on adjunct chemotherapy: FAM regimen(5-Fluorouracil, Adriamycin and Mitomycin). She was also placed on long term proton pump inhibitor therapy. She has sustained remarkable clinical improvement with resolution of all her initial symptoms and she is currently on regular clinic follow-up. More cases of Gastric Adenocarcinoma among young Nigerians are being reported. There is a need for more extensive studies on this and possibly an indication for commencing endoscopy screening at an earlier age among individuals presenting with recent onset dyspepsia.

Key words: Gastric; Adenocarcinoma; Young; Nigerians

© 2020 The Authors. Published by ACT Publishing Group Ltd. All rights reserved.

Oguntoye OO, Yusuf M, Olowoyo P, Erinomo O, Omoseebi O, Soje MO, Oguntoye OA, Fatudimu O.Gastric Adenocarcinoma in a Young Nigerian - A Case Report. Journal of Gastroenterology and Hepatology Research 2020; 9(2): 3150-3154 Available from: URL: http://www.ghrnet.org/index.php/joghr/article/view/2815

INTRODUCTION

Gastric cancer is the sixth most common malignancy worldwide, after cancers of the lung, breast, prostate, colon and rectum, and skin (non-melanoma), and it is the third cause of death of all malignancies worldwide[1]. The World Health Organization estimates that in 2018, gastric cancer accounted for 783,000 deaths worldwide[2].

The incidence of gastric cancer shows wide geographical variation. The high-risk areas are East Asia (China and Japan), Eastern Europe, Central and South America[1,3]. The low-risk areas are Southern Asia, North and East Africa, North America, Australia, and New Zealand.[1,3] Gastric cancer has a low prevalence in sub-Saharan Africa with the lowest incidence rates in Western Africa[4,5]. The majority of Gastric cancers occurs sporadically and mainly affects people over the age of 45 years and they are commonly caused by a combination of many environmental factors[6,7]. The incidence of Gastric cancer increases with age. In the United States the median age at diagnosis is 68 years[8]. In Nigeria, Gastric cancer accounts for 1.1-6.0%[5,9] of all cancers and the mean age at diagnosis is 56 years[5,10,11]. Gastric cancer is uncommon among young Nigerians.

Early gastric cancer has no specific symptoms, most symptoms of gastric cancer reflect advanced disease[12]. Therefore, patients with dyspepsia with any of the following ALARM features should be evaluated with upper GI endoscopy for early diagnosis of a possible gastric cancer: Age ≥ 50 years, Family history of upper GI malignancy in a first-degree relative, Unintended weight loss, GI bleeding or iron deficiency anemia, Dysphagia, Odynophagia, Persistent vomiting and Abnormal imaging suggesting organic disease[13].

In Nigeria and sub-Saharan Africa most patients present with advanced disease often complicated by gastric outlet obstruction, bleeding or perforation[10,14]. We report a case of Gastric adenocarcinoma in a young Nigerian presenting with features of gastric outlet obstruction.

CASE PRESENTATION

We present Mrs O.V. a 41year old Nigerian of the Yoruba tribe who presented at our Gastroenterology clinic with recurrent upper abdominal pain and weight loss of one year duration and vomiting of two weeks duration. She was apparently well until one year ago when she developed upper abdominal pain worse in the epigastrium of insidious onset, peppery/burning in nature, non-radiating, aggravated by eating and temporarily relieved with the use of antacids. Not a known patient with peptic ulcer disease, no history of NSAID or steroid use, no cigarette smoking, no consumption of alcohol, no consumption of smoked food items, no family history of gastric cancer. The pain became worse a month prior to presentation and has been progressive. There is associated progressive unintentional weight loss over the last one year despite intact appetite but she is afraid to eat because it worsens the epigastric pain. There is lethargy and occasional dizziness. No anterior neck swelling, no heat intolerance, no risk factors for HIV infection. There is amenorrhea; her last menstrual period was one year ago.

She started vomiting two weeks prior to presentation which was non-projectile, containing both recently ingested meals and partially digested stale food substances, vomitus was non-bilous. Episodes of vomiting is usually preceeded by abdominal bloating or feeling of indigestion. No haematemesis or melaena. No abdominal swelling, no constipation, no tenesmus, no jaundice.

Review of other systems was not contributory.

Clinical examination revealed a young woman, chronically ill-looking, not pale, anicteric, acyanosed, afebrile, had some dehydration, no digital clubbing, no significant peripheral lymph node enlargement, no pedal oedema and no asterixis. The Abdomen was scaphoid, moved with respiration, mild epigastric tenderness, no epigastric mass felt but had a positive succussion splash. The liver, spleen and kidneys were not palpably enlarged. No Ascites and the bowel sounds were normoactive. Digital rectal examination was normal. Examination of the other systems was also normal.

Provisional diagnosis was suspected Chronic Gastric Antral or Pyloric Channel Ulcer complicated by gastric outlet obstruction from cicatrization of the chronic ulcer to rule out Gastric Antral Adenocarcinoma.

Investigation results are as follows: Full Blood Count - PCV=47%, WBC=9,700 × 106/L (Neutrophils=54.6%, Lymphocytes=34.7%, Monocytes=9.8%, Eosinophils=0.3%, Basophils=0.6%), Platelets=259,000 × 106/L. ESR=14mm/hr. FBG=4.5mmol/L and 2HPP=5.7mmol/L. E,U&Cr - Na+=133mmol/L, K+=3.8mmol/L, Cl-=98mmol/L, HCO3=27mmol/L, Urea=4.6mmol/L, Creatinine=93umol/L.

Abdominal ultrasound scan: The stomach is markedly dilated and contains multiple floating coarse echoes, some of which settle at the dependent part consistent with food residues. There is abrupt tapering at the pylorus and associated pyloric wall thickening. No Ascites. The other intra-abdominal and pelvic organs and structures are within normal limits. Conclusion: Features are consistent with Gastric Outlet Obstruction.

Abdominal CT scan: Circumferential thickening of the gastric pyloric wall is seen with some narrowing of its lumen. The thickest part measures 12.6mm and the parts of the stomach is preserved. The other demonstrated bowel loops appear normal. No obvious enlarged lymph node seen. The Liver (span - 13.9 cm), intrahepatic ducts, vascular channels, gallbladder, pancreas, spleen (span - 7.34 cm) are preserved. No ascites seen. Both kidneys are normal positions, orientations, outlines, parenchymal density and preserved corticomedullary differentiation. The uterus, both adnexa and pouch of Douglas are normal. Conclusion: Pyloric antral mass? Carcinoma. Upper GI Endoscopy: Inflammed antrum (hyperaemic and oedematous) with friable, unhealthy appearing mucosa that bleeds with contact with the scope. Mucosa is uneven with multiple swellings / elevations (Figure 1). These lesions extend to involve the pylorus and the duodenal bulb sparing the gastric corpus, cardia and fundus. There are multiple areas of ulceration in the duodenal bulb with mucosal hyperaemia and oedema, and significant luminal narrowing that made it impossible to advance the scope further (Figure 2). Thus, the rest of the duodenum could not be visualized. Normal gastric ruggae and minimal fluid collection in the stomach cavity containing few food debris (Figure 3-5). Conclusion: (1) Suspected Gastric Antral Adenocarcinoma with Duodenal extension (2) Chronic Duodenal Ulcer complicated by Gastric Outlet Obstruction.

MHistology

MMacroscopy: Gastric Antrum: Specimen consists of 10 tiny pieces of firmly greyish white tissues which altogether measures 0.8cm in length.

MDuodenum: Received 4 tiny pieces of firmly greyish white tissues which altogether measures 0.4cm in length.

Microscopy

Gastric Antrum: Histologic sections show bizzare well to moderate well-formed glands lined by pleomorphic epithelial cells sharing large hyperchromatic nuclei with intracellular and extracellular mucin production. These are seen within an inflamed fibro-collagenous tissue.

Diagnosis: Gastric Antral, well differentiated adenocarcinoma (Figures 6 and 7).

Duodenum: Histologic sections are not remarkable. She was reviewed by the surgeons and a diagnosis of Distal Gastric Cancer was made. She had an elective exploratory laparotomy done under general anaesthesia. A Bilroth II procedure was performed: Partial Gastrectomy and Gastro-Jejunostomy. She subsequently was commenced on adjunct chemotherapy: FAM regimen (5-Fluorouracil, Adriamycin and Mitomycin). She was also placed on a proton pump inhibitor (Rabeprazole 20mg twice daily). She has sustained remarkable clinical improvement with resolution of all her initial symptoms and she is currently on regular clinic follow-up.

Figure 1 An Endoscopic image of the Gastric Antrum showing inflammed antrum (hyperaemic and oedematous) with friable, unhealthy appearing mucosa. The mucosa is uneven with multiple swellings / elevations, these lesions extend to involve the pylorus and the duodenal bulb.

Figure 2 An Endoscopic image of the Duodenum Bulb showing extensive ulcers with significant luminal narrowing due to fibrosis/cicatrization that made it impossible to advance the scope further. This is the cause of the Gastric outlet obstruction in this patient.

Figure 3 An Endoscopic image of the Descending colon.

Figure 4 Significant fluid collection in the gastric cavity despite an overnight fast of the patient in keeping with Gastric outlet obstruction.

Figure 5 An Endoscopic image of the Gastric Fundus showing normal appearance.

Figure 6 Micrograph showing malignant glands infiltrating the submucosa within a pool of mucin (x10 magnification).

Figure 7 Micrograph showing group of well differentiated malignant glands infiltrating the gastric submucosa and surrounded by pool of mucin (x4 magnification).

Diagnosis: Endoscopic features of an Extensive Ulcerative Colitis (Proctitis with Pancolitis).

Histology

Macroscopy: (1) Ascending colon: Specimen consists of 4 pieces of tiny greyish white tissue all together measuring 0.8cm × 0.5cm; (2) Transverse colon: Specimen consists of 5 pieces of tiny greyish white tissue all together measuring 0.8cm × 0.5cm; (3) Descending colon: Specimen consists of 5 pieces of tiny greyish white tissue all together measuring 0.7cm × 0.5cm; (4) Sigmoid colon: Specimen consists of multiple pieces of tiny greyish white tissue all together measuring 1cm × 0.4cm; (5) Rectum: Specimen consists of 4 pieces of tiny greyish white tissue all together measuring 0.5cm × 0.5cm

Microscopy: Sections from the ascending, transverse, descending, sigmoid colon and rectum are essentially the same. The sections show focal erosions to variable ulcerations, crypts distortion, variable glandular atrophy, focal loss of mucin, glandular destruction, glandular distortion and glandular regeneration. There are neutrophils infiltrating and destroying some of the glands. There are foci of abscesses in the mucosa and submucosa. However, chronic changes are accentuated. The lamina propria shows a dense infiltration by lymphocytes, plasma cells and eosinophils.

Diagnosis: Features strongly indicate Ulcerative Colitis (Figure 6).

Upper GI Endoscopy revealed essentially normal findings. No abnormality was detected.

Histology

Macroscopy: (1) Gastric antrum: Specimen consists of 4 pieces of tiny greyish white tissue measuring 0.5cm x 0.5cm; (2) Gastric corpus: Specimen consists of 3 pieces of tiny greyish white tissue measuring 0.5cm x 0.3cm.

Microscopy: Gastric antrum: Histologic sections of gastric antral biopsy with intact mucosa. There is infiltration of lamina propria by lymphocytes, plasma cells and few neutrophils. There is mild glandular atrophy, no dysplasia, no intestinal metaplasia and no HLOs seen.

Diagnosis: Chronic non-specific antral gastritis with mild atrophy, no activity, no metaplasia.

Gastric corpus: Histologic sections of gastric corpus show intact mucosa. The lamina propria shows no significant inflammation. There is no glandular atrophy, no dysplasia, no intestinal metaplasia and no HLOs seen.

Diagnosis: No histologic diagnosis, He was commenced on Tab Mesalamine 800mg three times daily and antioxidants to be taken initially for three months. He was at the same time also commenced on Tabs Ofloxacin and Metronidazole for one week. He presented at our clinic three months later with complete resolution of all the symptoms. He was unwilling to undergo another colonoscopy for follow-up despite adequate counselling. The Tab Mesalamine was reduced to 800mg twice daily and he was scheduled for regular clinic follow-up.

Conclusion

Ulcerative Colitis is rare in our environment. It runs a chronic relapsing course and patients usually present with recurrent rectal bleeding, frequent stools, mucous discharge from the rectum, tenesmus, lower abdominal pain and a low-grade fever. The diagnosis of ulcerative colitis is best made with colonoscopy and mucosal biopsy for histopathology. The treatment of ulcerative colitis is mainly medical and includes use of amino-salicylates (such as mesalamine, sulphasalazine), corticosteroids, anti-inflammatory agents, antidiarrheal agents, and rehydration. Surgery is only considered if medical treatment fails or if a surgical emergency develops such as toxic megacolon or intestinal perforation. Even though Ulcerative Colitis is uncommon in our environment, it is important for physicians to have a high index of suspicion for this condition particularly in a young individual with recurrence of the characteristic symptoms. Early diagnosis and treatment will prevent complications that could develop if untreated. There is a need to have a national database on Ulcerative Colitis in Nigeria and availability of colonoscopy services across the country to aid early diagnosis of this condition.

Acknowledgement

Special thanks to the House Officers and Resident Doctors in the Gastroenterology unit of the Department of Internal Medicine for their support in making this publication a reality. The authors did not receive any financial support from any individual, group or organization towards this research work.

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