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A CASE OF ABDOMINAL LUMP

Name : M.Varalakshmi

Age : 70 Sex: F

Address : Nalajarla & daily labourer

Chief complaints: ( 11.08.2016)


Fever since 1 month
Swelling in left side of abdomen since 15 days.
black coloured stools with mucus since 15 days

H/O Present illness :


Fever since 1 month which is low grade, intermittent , more during
evening time, not associated with chills and rigors.

swelling in left side of abdomen since 15 days insidious onset, gradually


progressive. Not associated with any pain.
Black coloured hard stools, with mucus since 15 days. No h/o frank blood.
Constipation +nt
H/o loss of appetite and loss of weight present .
No h/o burning micturition / urgency/ increased frequency/ haematuria .
No h/o breathlesness / haemoptysis/ chest pain.
H/o bony pains

Co morbidities : nil.
PAST HISTORY : no similar complaints in the past.
no h/o PTB/ asthma/ CAD/ CVA/
jaundice/ epilepsy
h/o 2 c sections 40 yrs back

PERSONAL HISTORY: mixed diet


smoked : 1 year ( @18 )
non alcoholic
menopause 20 yrs back
FAMILY HISTORY : not relavent
DRUG HISTORY : not on any medication,
not allergic to any drugs.
GENERAL EXAMINATION
O/E: conscious, cohorent & well oriented to time , place and person
Moderately built and ill nourished.
Pallor present.
No cyanosis / icterus / clubbing / lymphadenopathy / oedema
Vitals : PR: 82 / min
BP : 110/80 mmhg
RR : 16 /min
TEMP : 98.2 F
Local Examination
EXAMINATION OF THE ABDOMEN : supine position
Lax skin, linear midline c sec scar
Fullness in left lumbar region, with swelling moving with respiraton
Single swelling of 10 * 8 cms palpable extending from left costal
margin superiorly, lateral border of rectus muscle medially, inch
medial to midaxillary line laterally, iliac crest inferiorly.
non tender, with smooth surface, well defined margins,
firm in consistency, freely movable in all directions, ballotable.
Intra abdominal , intraperitonial
Hepatomegaly : 10 cms below costal line, surface is smooth.
No palpable nodes in supra clavicular fossa or inguinal region.
Dull note on percussion
P/R : sphincter tone normal, rectal mucosa freely movable, no induration or
masses felt, glove stool stained
P/V : b/l fornices free/ no palpable masses.
OTHER SYSTEMS
CVS : s1 s2 +nt, no murmurs
CNS : no focal deficits
RS : BAE +nt, no added sounds.
Provisional diagnosis

??? GIST
Investigations:

Hb 7.5 gm/dl
Twbc 9700 cells/cu mm ; P- 59 L-32 E- 5 M- 2
Platelet count 3.7 lakh/cu mm

LFT : T.Bilurubin 0.3 mg/dl


Direct 0.1 mg/dl
AST-35 IU/ml ALT-18 IU/ml ALP-135 IU/ml
S.Proteins total 5.6 gm/dl ; Albumin:1.9 gm/dl

RFT : UREA 19 mg/dl , CREATININE 0.6 mg/dl


Urine routine : ALB and SUG nil, RBC - nil,
Pus cells : 1-2/HPF, Epi cells : 3-4/HPF
HbsAg/HCV/HIV: Non reactive
Ca 125 : 16.16 (0-35 U/ml)
USG Abdomen:
- Small bowel (jejunum) diverticulum mass ?malignancy
- Hepatomegaly with liver secondaries.
FNAC from lumbar mass : ( 13.08.2016)
Suggestive of Mixed Fungal and Bacterial infection.
- Contamination has to be ruled out.

FNAC from liver lesion : (18.08.2016)


Suggestive of inflammatory pathology.

CT Abdomen : (23.08.2016)
- Left lumbar and iliac fossa large necrotic mass with jejunal communication
D/D : Jejunal diverticulum Adeno carcinoma
Malignant GIST
Actinomycosis
- Multiple progressive enhancing hypodense lesions in both lobes of liver Malignant /
Fungal etiology.

FNAB from liver lesion : ( 29.08.2016)


Suggestive of Spindle cell neoplasm, possible metastasis from
GIST.
CD117- Negative
.

Plan of surgery: LAPROSCOPY &


PROCEED
But due to high risk of the patient
(anemia& cardiac risk), laprotomy was
done under regional anasthesia on
19/9/16
Surgery
Mid midline incision given.
INTRAOP FINDINGS:
Mass is cystic,adherent to mesentry of jejunum
Communication to jejunum present from the mass
Small white superficial lesion in right lobe of liver.
Nodular mass in left lobe of liver
Ascites present
No para aortic nodes
Procedure
Excision of mass with proximal jejunum involved.
End to end anastomosis of jejunum done.
Superficial nodular lesion over liver taken for
biopsy
Feeding jejunostomy done for nutritional purpose
of the patient.
Post operatively Noradrenaline drip was continued
because of intraop hypotension.
Enteral feeding through Feeding jejunostomy
started on day 2.
Discharged on pod-8.

Final biopsy : GIST with LIVER


secondaries.
CD117- +ve

Patient is on imatinib at present.


Thank you

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