Gastroenterology Case Studies

-->

DISCHARGE SUMMARY

The patient, a 43-year-old white man, a chronic alcoholic with advanced cirrhosis and hiatus hernia, developed distal esophageal stenosis.  An acute attack of dysphagia and choking led to hematemesis.  The patient began to lose weight 10 months ago, and 5 months later his abdomen began to swell, and he quickly regained the 30 pounds he had lost.  He had no dysphagia nor recognized bleeding.  The day before he was first examined, he suddenly became unable to swallow while eating lunch.  He choked and coughed, vomited hard, and then brought up a cupful of fresh blood.

Examination upon hospitalization showed moderate chronic illness, but no apparent acute problem at the moment.  There had been no further bleeding.  The vital signs were normal.  There were classical signs of alcoholic cirrhosis, hepatomegaly, spider angiomata, and muscle wasting about the shoulders and zygomas.

LABORATORY FINDINGS

Tube aspiration of the stomach showed no blood.  Admission hemoglobin was 12 g and hematocrit 38.  The serum alkaline phosphatase was 17 King-Armstrong units and serum bilirubin 2 mg.

X-RAY STUDIES:  Upper gastrointestinal roentgen study was interpreted as showing a small direct hiatus hernia, distal esophagitis, and a low-grade esophageal stricture secondary to the esophagitis.  Esophageal varices could not be demonstrated.  Except for hiatus hernia, the stomach and duodenum were considered normal.

HOSPITAL TREATMENT

The day following hospitalization, esophagogastroscopy was carried out.  Direct hiatus hernia and esophagitis were confirmed.  Varices were not found.  There was no esophageal stricture; instead, the distal esophagus seemed soft and mobile, and permitted easy passage of the 10-mm esophagoscope.  A
6 x 5-mm irregular ulcer was found in the hyperemic mucosa just above the esophagogastric junction.  There was no Mallory-Weiss lesion.

PATHOLOGIST’S REPORT

Esophageal biopsy specimens contained adenocarcinoma.  Peritoneoscope examination showed metastases scattered over a finely nodular cirrhotic liver.

FINAL DIAGNOSES

1. Primary adenocarcinoma of the herniated gastric cardia with extension up the esophagus and hepatic metastases.

2. Alcoholic cirrhosis.

3. Hiatus hernia, uncomplicated.

4. Esophagitis.

FOOTNOTE

Lines 7 (Page 1)-6 (Page 2).  The physician dictates incorrect usage of semicolons and commas several times in the report, and corrections were made in the transcript.

Line 10 (Page 1).  Begun was changed to began to correct grammar.

Line 1 (Page 2).  The diagnoses were enumerated for clarity.