P3123 - Air Under the Diaphragm: A Rare Presentation of Gastric Adenocarcinoma

Charudatta Wankhade, MD¹, Kristen L. Farraj, DO¹, Bobby Jacob, MD², Pranay Srivastava, MD¹, Shino Prasandhan, MD¹, Jiten Desai, MD^1
1Nassau University Medical Center, East Meadow, NY; ²Nassau University Medical Center, Lake Grove, NY

Introduction: The incidence of perforation in patients with gastric adenocarcinoma is less than 1%. Majority of perforations occur in advanced disease (Stage IV). Very rarely a perforation may occur in an early stage. We report a case of perforation in a patient in whom the surgical management was changed from patch repair to partial gastrectomy after a pre-op endoscopic diagnosis of malignancy.

Case Description/Methods: A 51 year old Indian female with no past medical history presents to the emergency room for new onset epigastric pain. Review of systems was positive for lethargy and significant weight loss of 20lbs in the past 6 months. She denied fever, chest pain, diarrhea, hematemesis or melena. On evaluation she was in moderate distress, hemodynamically stable and afebrile. On the physical exam her abdomen was tender with guarding and rigidity. Laboratory findings were significant for microcytic anemia with a hemoglobin of 8 g/dL. Computed Tomography (CT) imaging reported air under the diaphragm with distal gastric wall thickening suggestive of ulcer or malignancy. Surgery was consulted and she was scheduled for an urgent exploratory laparotomy. Gastroenterology was consulted for endoscopic evaluation of the gastric wall thickening seen on CT scan in order to determine the appropriate surgical management. Endoscopy was performed in the operating room, which revealed a 2 cm, ulcerated, mass-like lesion in the antrum. Subsequently, the patient had a subtotal gastrectomy with billroth II reconstruction. Pathology was suggestive of poorly differentiated carcinoma (pT3) with mucin and signet ring cell features. To date the patient is on Xeloda/Oxaliplatin chemotherapy.

Discussion: In most cases gastric adenocarcinoma is not suspected as the cause of perforation prior to emergency laparotomy and malignancy is often a postoperative diagnosis. In addition to adenocarcinoma, gastric wall thickening on CT scan, may also be seen in conditions like peptic ulcer disease, sarcoidosis, gastritis, amyloidosis and lymphomas. Although perforation is mainly seen in advanced gastric cancer as in our patient, early gastric cancer may present as perforation and may be missed after surgical patch repair of the perforation. Endoscopic evaluation in select cases may aid in deciding which surgical management may provide the most favorable outcome for the patient. Surgical treatment should aim to manage both the perforation and the oncologic aspect of the disease as in our patient followed by chemotherapy for improved survival.


Figure: Figure 1: Slide A demonstrates the initial chest x-ray showing air under the diaphragm. Slide B demonstrates the mass that was visible during the screening esophagogastroduodenoscopy for the gastric wall thickening. Slide C and D are the pathology slides showing invasive carcinoma with mucin and signet cell features demarcated by the blue arrows.


Disclosures:
Charudatta Wankhade indicated no relevant financial relationships.
Kristen Farraj indicated no relevant financial relationships.
Bobby Jacob indicated no relevant financial relationships.
Pranay Srivastava indicated no relevant financial relationships.
Shino Prasandhan indicated no relevant financial relationships.
Jiten Desai indicated no relevant financial relationships.


Charudatta Wankhade, MD¹, Kristen L. Farraj, DO¹, Bobby Jacob, MD², Pranay Srivastava, MD¹, Shino Prasandhan, MD¹, Jiten Desai, MD¹. P3123 - Air Under the Diaphragm: A Rare Presentation of Gastric Adenocarcinoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.