Presentation
This patient known to have gastric cancer was on neoadjuvant chemotherapy. She had 24h of vomiting. Suspected perforation.
Patient Data
There is gas outlining the gastric wall. Marked small bowel dilatation. No free gas.
The patient underwent partial gastrectomy.
Distal gastrectomy: A subtotal distal gastrectomy, received opened. Greater curve 110mm in length, lesser curve 45mm in length with attached omentum up to 320mm.Proximal margin inked blue, distal margin inked green and circumferential margin/serosa inked black. 18mm from the proximal margin and 30mm from the distal margin is a poorly demarcated ulcerated firm tan tumor with rolled edges 40x32mm. The tumor invades through muscularis propria into the perigastric tissue to a depth of 10mm. The tumor is 3mm from the circumferential resection margin and serosa underlying the tumor is roughened and puckered. Adjacent to the tumor is a poorly defined patch where the mucosa is roughened and dark brown 50x45mm. The remaining mucosa appears unremarkable. Within the fat are multiple rubbery ovoid lymph nodes up to 10mm. Fat placed into Carnoy's.
MICROSCOPIC DESCRIPTION:
The sections of stomach show invasive poorly differentiated adenocarcinoma of intestinal type. This arises in the floor of an ulcer involving transitional zone and antral mucosa. Tumor consists of poorly formed glandular structures lined by a stratified arrangement of cuboidal and columnar epithelial cells. These show moderate nuclear pleomorphism. Frequent mitotic figures are identified. Tumor extends through the full thickness of the muscularis propria into immediately adjacent omental adipose tissue to 1mm from the omental free serosal surface. No evidence of vascular, lymphatic or perineural invasion is seen. Immediately adjacent gastric mucosa shows moderate regenerative and inflammatory atypia with both acute and chronic inflammatory cells noted within the lamina propria. H. pylori are not identified. Sections from themacroscopically noted brown roughened mucosal area show full thickness benign mucosal ulceration. The distal margin passes through antral mucosa and is clear of tumor. The proximal margin passes through gastric body type mucosa and is also clear of tumor. The free serosal surface of stomach and the radial resection margin through gastric omentum are clear of tumor. No evidence of metastatic tumor is seen in any of 12 lymph nodes.
Extensive gastric mural gas is demonstrated, with associated portal venous gas in the left lobe of the liver. There is no intraperitoneal free gas demonstrated. There is mural thickening of the gastric antrum, duodenum and proximal jejunum. Some of the mid to distal small bowel also shows mural thickening in the right iliac fossa, though less severe than the proximal changes. The small bowel is dilated, measuring up to 4 cm in diameter, however there is no transition point to indicate that this is a mechanical obstruction, and fecal matter are seen throughout the colon.
PostOp for suspected bowel ischemia
Evidence of interval partial gastrectomy noted. The nasogastric tube has been advanced and is now positioned within the jejunum. Left-sided presumed intra-abdominal drain surgical drain noted. Moderate free fluid is observed (9HU) in perihepatic, perisplenic, trackingalong both paracolic gutters and pooling within the pelvis. This is likely related to patient's post-operative state.There is no evidence of abnormal bowel dilatation or increased/decreased segmental mucosal wall enhancement. The gastric cavity is largely decompressed in the presence of the jejunal catheter. There is no abnormal small bowel mucosal thickening observed. When compared to previous imaging, the previously demonstrated abnormal-appearing duodenum and jejunum and associated gastric gastric mural and portal venous gas within the left lobe of the liver have resolved.
Case Discussion
Gastric emphysema is rare and often alarming especially when associated with portal venous gas. As in bowel, ischemia is a cause. In this case, it may have related to the NG tube and vomiting, or alternatively due to the ulcerating cancer, however there was no perforation.
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