Massive gastric distension due to signet‑ring cell gastric adenocarcinoma

Abstract

Chronic massive gastric distention is a rare condition that can occur due to an underlying obstruction or dysmotility. Gastric outlet obstruction (GOO) is often the culprit that can manifest as the result of the luminal, mural, or extrinsic compression. Gastric adenocarcinoma can rarely manifest as massive gastric distention due to partially obstructing mass or peptic stricture. Severe and fatal sequelae may develop, if early detection and appropriate intervention are delayed, such as gastric decompression, endoscopic evaluation and/or surgical resection. Herein, we present a case of a 60‑year‑old male who presented with progressive worsening of nonspecific symptoms over the 8‑month period. He was found to have remarkable massive gastric distention on imaging which was chronic in etiology secondary to GOO due to metastatic signet‑ring cell gastric adenocarcinoma.

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Volume 9 / Issue 5 / May 2020
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Introduction
Gastric outlet obstruction (GOO) is a clinical syndrome
where the patient presents with progressive epigastric pain,
postprandial nausea, vomiting, early satiety and distention
due to gastric or duodenal mechanical obstruction. Gastric
adenocarcinoma can rarely manifest as massive gastric distention
due to partially obstructing mass or peptic stricture. Severe fatal
sequelae can develop if early detection and intervention with
gastric decompression or resection are delayed. The treating
physicians should have a high index of suspicion for the
above,especiallyinchroniccaseswithnonspecicsymptoms
on presentation.
Case History
A 60‑year‑old African‑American male patient presented to the ED
complaining of progressively worsening diffuse abdominal pain,
intermittent nausea and vomiting, early satiety, and 25 lb weight loss
over the last 8 months. He described normal bowel movements
and passing gas. He denied any fever, hematemesis, or melena.
Onexamination:pulse84bpm,temp36.6°C,BP144/68,andRR
18 bpm. His BMI was 22 kg/m2. He was alert and oriented with
mild distress due to abdominal pain. His abdomen was mildly
distended with tympanic percussion note, active bowel sounds,
and positive succession splash.
His lab results revealed WBC 4.7 k/mcl, Hgb 12.9 mg/dL, and
normal basic metabolic panel. Computed tomography scans
of the abdominal revealed markedly distended stomach with
debris extending to the pelvis with a mass effect on surrounding
abdominal structures [Figure 1].
Massive gastric distension due to signet‑ring cell gastric
adenocarcinoma
Ali Zakaria1, Fizan Khan2, Shehbaz Ahmad3, Issam Turk1, Jay Levinson1
1Department of Internal Medicine, Section of Gastroenterology, Ascension Providence Hospital/Michigan State University
College of Human Medicine, Southfield, 2Mercy Health, Michigan State University College of Human Medicine, Grand Rapids,
MI, 3American University of the Caribbean, School of Medicine, USA
Abs tr Ac t
Chronic massive gastric distention is a rare condition that can occur due to an underlying obstruction or dysmotility.
Gastric outlet obstruction (GOO) is often the culprit that can manifest as the result of the luminal, mural, or extrinsic
compression. Gastric adenocarcinoma can rarely manifest as massive gastric distention due to partially obstructing mass or
peptic stricture. Severe and fatal sequelae may develop, if early detection and appropriate intervention are delayed, such as
gastric decompression, endoscopic evaluation and/or surgical resection. Herein, we present a case of a 60‑year‑old male who
presented with progressive worsening of nonspecific symptoms over the 8‑month period. He was found to have remarkable
massive gastric distention on imaging which was chronic in etiology secondary to GOO due to metastatic signet‑ring cell
gastric adenocarcinoma.
Keywords: Gastric outlet obstruction, massive gastric distension, signet‑ring cell gastric adenocarcinoma
Case Report
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DOI:
10.4103/jfmpc.jfmpc_170_20
Address for correspondence: Dr. Ali Zakaria,
16001 W Nine Mile Rd, Department of Internal Medicine,
Southfield, MI 48075, USA.
E‑mail: alizakaria86@hotmail.com
How to cite this article: Zakaria A, Khan F, Ahmad S, Turk I, Levinson J.
Massive gastric distension due to signet-ring cell gastric adenocarcinoma.
J Family Med Prim Care 2020;9:2558-61.
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Received: 27‑01‑2020 Revised: 13‑03‑2020
Accepted: 26‑03‑2020 Published: 31‑05‑2020

Zakaria, et al.: Massive gastric distension due to signet‑ring cell gastric adenocarcinoma
Journal of Family Medicine and Primary Care 2559 Volume 9 : Issue 5 : May 2020
He was treated conservatively with intravenous uid, PPI,
and nasogastric tube placement with 3 L of  uid removed
over 24 h. EGD revealedulcerated, par tiallyobstr uctive
pyloric malignant appearing lesion with a large amount of
retained bezoar (food) [Figure 2]. The patient underwent
distal subtotal gastrectomy with Roux‑en‑Y reconstruction
and liver biopsy. Histopathology confirmed metastatic
transmurally invasive poorly differentiated mucinous
signet‑ring cell adenocarcinoma (pT4bN3aM1) [Figure 3].
Immunohistochemistry was negative for HER2. The liver biopsy
revealed micronodular cirrhosis grade II, stage IV.
He was discharged in a stable condition with outpatient follow
up with oncology to discuss possible palliative chemotherapy
versus comfort measures given his underlying cirrhosis and poor
overall prognosis.
Discussion
GOOis aclinicalsyndromewherethepatientpresentswith
progressive epigastric pain, postprandial nausea, vomiting,
early satiety and distention due to gastric or duodenal
mechanical obstruction. It rarely progresses to massive
gastric distention, which can be complicated with gastric wall
ischemia, perforation, and death. Massive gastric distention was
rstdescribedbyDuplayin 1833,mostlyasapostoperative
complication.[1]
TheunderlyingetiologyofGOOhaschangedsubstantiallyover
the last 5 decades. Benign etiologies (with peptic ulcer disease
being the most common) accounted for more than 90% of the
casesupuntilthelate1970s.Giventheincreaseduseof PPIs
along with the decreased incidence of Helicobacter Pylori related
ulcers, malignant etiologies have recently accounted for almost
80% of the cases.[2‑4] Multiple gastrointestinal malignancies
can present as GOO, with pancreatic adenocarcinoma with
duodenal involvement and gastric adenocarcinoma being more
common.
Gastricadenocarcinomaisimportanttoconsiderdespiteitsrarity
in the western countries likely due to the decreased prevalence
of H. pylori.[5‑7] Other less common malignancies include gastric
lymphoma, neuroendocrine tumors, local extension of biliary
malignancies, and duodenal adenocarcinomas. Benign etiologies
include PUD, Crohn’s disease, pancreatitis, prolapsed gastric
polyps, eating disorders,[8] gastric bezoar, gastric volvulus,
Bouveret syndrome,[9] and superior mesenteric artery syndrome.[10]
The most common clinical features of  GOO are epigastric
pain, postprandial vomiting, distention, early satiety, and
weight loss.[11] On rare occasions, patients may present with
progressively worsening abdominal distention with massive
gastric enlargement.[12] In cases of acute presentation, the patient
can decompensate rapidly with gastric wall ischemia and necrosis,
which may inevitably lead to perforation and peritonitis. This
rarelyoccursasthestomachiswellprotectedduetosignicant
collateral circulation. The main underlying pathophysiologic
explanation is signicant venous insufciency with the point
of tension needed to cause mucosal ischemia documented as
14 mmHg.[1,13]
The treating physicians should have a high index of suspicion
of GOOwhenapatientpresentswithatypicalclinicalfeatures.
If symptoms are chronic in nature, early detection could be
difcult assymptoms of weight loss,early satiety, andnausea
mightbenonspecic and canbeexplained by obstruction or
gastric dysmotility.
Initial workup should include basic laboratory blood tests which
can reect dehydration and electrolyte disturbances due to
prolonged vomiting.[14] It might also reveal low hemoglobin due
to chronic blood loss. Imaging studies including plain abdominal
X‑ray,bariumstudies,andCTscancanrevealsignicantgastric
enlargement,retainedgastriccontent,air‑uidlevel,andpossibly
an underlying malignancy in the gastrointestinal tract.[15,16]
Figure 1: (a) Computed tomography (CT) scan of the abdomen and
pelvis (coronal) reveals markedly distended stomach with ingested
debris extending to the pelvis with a mass effect on surrounding
abdominal structures. (b) CT scan of the abdomen and pelvis (sagittal)
reveals markedly distended stomach with ingested debris extending
to the pelvis with a mass effect on surrounding abdominal structures.
(c) CT scan of the abdomen and pelvis (axial) reveals markedly
distended stomach with ingested debris extending to the pelvis with a
mass effect on surrounding abdominal structures
c
b
a
Figure 2: Esophagogastroduodenoscopy (EGD) reveals large amount
of retained bezoar/food (a and b) and ulcerated; partially obstructive
pyloric malignant‑looking lesion (c and d)
d
c
b
a

Zakaria, et al.: Massive gastric distension due to signet‑ring cell gastric adenocarcinoma
Journal of Family Medicine and Primary Care 2560 Volume 9 : Issue 5 : May 2020
If the initial diagnostic work‑up reveals massive gastric distention,
the patient should be treated with nothing by mouth, IVF
hydration,electrolytereplacement,andNG‑tubedecompression
to decrease the risk of  complication which includes: Gastric
wall ischemia, necrosis, perforation, and aspiration. PPI should
beusedinallcasesasitcandecreasegastricinammationand
secretions; also as empiric treatment for possible underlying
pepticulcerdisease.EGDshouldbeperformedtoevaluatethe
underlying pathology. In cases of ulceration or the presence
of amass,biopsiescould beperformedto conrmunderlying
etiology. Poor sensitivity has been described with the use of
routine biopsy techniques if the tumor is extraluminal or does
not involve the mucosa.[3,17]
If gastric adenocarcinoma is confirmed as the cause, the
patient should undergo proper staging which includes further
imaging and complete oncology evaluation. The treatment
should be individualized according to the stage of the disease,
resectability or lack thereof, and overall performance status
of the patient.[18] Treatment options include chemotherapy,
palliative endoscopic stent placement and surgical resection or
bypass. Endoscopic stent placement is associated with fewer
complications, shorter hospital stay, lower costs, and quicker
interval to oral intake, however, decreased food intake and stent
complications may develop shortly after.[17‑19] Surgical resection
with gastroenterostomy provides better technical success and
longer survival.[19,20] Despite successful curative resection, the
5‑year survival rate for gastric cancer is 31.5% thus long‑term
survival remains poor.[21]
Conclusion
Gastric adenocarcinoma can rarely manifest as massive
gastric distention due to partially obstructing mass or peptic
stricture. Severe fatal sequelae can develop if early diagnosis
and intervention with gastric decompression or resection are
delayed. The treating physicians should have a high index
of suspicion especially when the presentation is chronic in
nature and accompanied by non‑specific signs and symptoms.
Ethics statement
The case report was performed in accordance with the
ethical standards. The case was presented to the Ascension
Providence Hospital Research Committee. The patient signed
an informed consent form to share his images and other
clinical information for publication. He understands that all
efforts will be made to conceal his identity, but anonymity
cannot be guaranteed.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published and
due efforts will be made to conceal their identity, but anonymity
cannot be guaranteed.
Acknowledgment
Authors would like to express their deepest appreciation to
Dr. Juanita Evans for her valuable expertise in providing and
reading the histopathology slides, and to Dr. Aruj Chawla for
providing and interpret the diagnostic images.
Financial support and sponsorship
Nil.
Conflicts of interest
Therearenoconictsof interest.
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