A 60 year old man from Moyale (Kenya) was treated for PUD for many years.
He was admitted in our hospital because of severe dehydration.
He was unable to retain anything. The complaint was that either solid or
liquid food was reaching up to the lower part of the chest and then was coming
up immediately and undigested.
The patient was anemic and had very swollen legs.
PAST MEDICAL HISTORY
At the beginning he was complaining of burning epigastric pains which
were reaching up to the mouth, like in gastro-oesophageal reflux disease.
Then later there was inability to swallow solid food while he could
drink and take porridge. Now even drinking or swallowing saliva was impossible.
The patient was sent for U/S, which showed a much enlarged liver with
multiple hypoechogenic masses, looking like mts.
There was ascites. Pancreas was normal and kidneys were regular. There
was no splenomegaly.
The patient thereafter was sent for barium meal. Report was: “very tight
structure of the distal 1/3 of the esophagus.
A gastroscopy confirmed the presence of an impassable stricture at 30 cm
below the incisors: the stricture was caused by a hard mass, covered with
fibrin, easily bleeding on touch. It was not possible to proceed further due to
severe stenosis.
Patient was referred to KNH on relatives’ request, after receiving 1
pint of blood (HB was 5g/dl).
LEARNING POINTS
- Dysphasia is to be considered a danger sign for CA esophagus.
- Severe dehydration together with inability to swallow is suspicious of CA esophagus.
- HIV test in this patient was negative, even tough AIDS could give a similar picture due to wasting (“slim disease” and severe oral and esophageal thrush).
- CA esophagus is very malignant and causes mts very quickly. It kills patients quickly.
- Anemia in those patients is partly due to chronic microscopic bleeding, partly to chronic inflammation, and partly to malnutrition.
- Oedema is related to low albumin levels, due to inability to feed.
- At KNH the patient was not operated because of extensive mts. A percuteneous gastrostomy was performed in order to feed him.
- Chemotherapy was attempted but patient died in 6 months time.
- It is therefore a very malignant carcinoma.
- Males more affected than females. More common beyond 50 years of age.
GLOSSARY
U/S: ULTRASOUND
PUD: PEPTIC ULCER DISEASE
MTS: METASTASIS
CA: CARCINOMA
KNH: KENYATTA NATIONAL HOSPITAL (NAIROBI)
Dr Giuseppe Gaido
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