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< Case history>
A 74 y/o male
was otherwise healthy until 2 months earlier, when he began to
suffer acid regurgitation after meal. He was a case of
hypertension under regular medication. He took alcohol 高梁
80-100ml/day for 30 years and smoking 1pack per day for
40years. He visited LMD for help , where gastroenteroscopy was
performed and revealed one shallow ulcer at middle body
posterior wall of stomach, malignancy could not be ruled out
by pathology. He was transferred to our hospital for furthur
survey.
Besides, he denied other associated symptoms include:
hunger pain, midnight pain, hiccup, dysphagia, constipation
/diarrhea, anorexia and body weight loss. He received
gastroendoscopy again and re-biopsy revealed adenocarcinoma,
so he was admitted for cancer staging.
On physical examination, the patient appeared general
well-being. His consciousness was clear and oriented. The
blood pressure was 150/90 mmHg. The temperature was 36.6 °C
the pulse rate was 80 /min, and the respiration rate was
16/min. The head was normal, and the conjunctivae were not
pale. The sclerae were not icteric. The neck was supple
without lymphadenopathy. The jugular vein was not engorged.
The breathing sounds were bilaterally clear. The heart beats
were regular without murmur. The abdomen was soft and flat; no
tenderness or rebound tenderness was noted. The liver and
spleen were not palpable. The extremities moved freely without
edema or petechiae.
<Lab
data>
CBC
|
WBC
K/μL
|
RBC
K/μL
|
Hb
g/dL |
Hct
% |
MCV
fL |
MCH
pg |
MCHC
g/dL
|
PLT
K/μL
|
Seg
% |
Eos
% |
Baso
% |
Lym
% |
|
4.41 |
4000 |
13.7 |
39.4 |
98 |
29.9 |
37 |
141 |
57.3 |
3.6 |
0.7 |
32.7 |
Chemistry and tumor marker
|
Alb
g/dL
|
Glo
g/dL |
T-Bil
mg/dL
|
D-Bil
mg/dL
|
AST
U/L |
ALT
U/L |
ALP
U/L |
LDH
U/L |
BUN
mg/dL
|
Cre
mg/dL
|
|
4.3 |
3.2 |
0.6 |
0.2 |
21 |
18 |
140 |
400 |
16.8 |
1.3 |
|
UA
mg/dL
|
Na
M |
K
M |
Cl
M |
(T)Ca
M |
Sugar
mg/dL
|
|
|
|
|
|
5.7 |
141 |
4.2 |
107 |
8.9 |
113 |
|
|
|
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<Special exams>
Gastroenteroscopy (Fig1 ) 90-10-8
EUS revealed gastric
mucosa lesion without regional lymph nodes involved
UGI
series, Abdominal CT, and Bone scan were
unremarkable
<Clinical course and
Treatment>
He received surgical intervention with total gastrectomy +
Roux-en-Y anastomosis + splenectomy. The pathologic finding
shows malignant epithelial cells which had spread through the
upper gastric mucosa but had not yet penetrated even to the
muscularis mucosae and the lymph nodes revealed no metastases.
The final diagnosis was early gastric cancer (EGC)
 病案分析
病人因胃酸逆流症狀求診，雖然沒有合併 "Alarm sign"(包含Anemia, BWL, anorexia,
dysphagia and melena)，但病人的年齡>40
y/o，所以必須考慮上消化道內視鏡檢查，此病例的內視鏡檢查顯示胃潰瘍位於胃體部中段後壁middle body
posterior，不平整的潰瘍底部和邊緣，週邊有皺摺中斷和杵狀皺摺的徵象。這些macroscopic
findings必須考慮惡性的可能，因此必須切片檢查而切片結果顯示惡性，故病人需接受進一步的cancer
staging，以決定治療方針和評估預後。本病人是個早期胃癌病例,
所謂早期胃癌指癌細胞僅侵犯黏膜層或黏膜下層。可分為：Ⅰ隆起型、Ⅱ表面型、Ⅲ凹陷型等三種。進行性胃癌又可分為四型：（1）隆起型（2）潰瘍型（3）潰瘍浸潤型（4）瀰漫性浸潤型.
早期胃癌與進行性胃癌的預後有顯著差別；五年存活率，在早期胃癌可高達90%以上，而進行性胃癌則不到30%.
早期胃癌的發生可以說幾乎沒有什麼症狀，患者常常沒有任何自覺，如果有的話，也只是些微的腹痛、噁心或是上腹部脹氣. 診斷方面,
上消化道內視鏡檢查除了可觀察胃部黏膜細微變化外，並且可以進行活體切片的病理檢查及細胞學檢查，準確度高達95%以上.
上消化道X光攝影無法做切片檢查，對於較小的病灶或是早期胃癌不易診斷出來.
胃癌的治療方式以外科手術切除為主，必須採用廣泛性切除，包括胃部腫瘤及其周圍組織和淋巴結.
早期胃癌，由於癌細胞只侷限在粘膜層，淋巴結的轉移機率較低，所以可採用內視鏡粘膜切除術(endoscopic mucosal
resection,
EMR)來加以根除，因而無須剖腹來進行胃切除，該種方式對於本身年紀已大或合併有其他嚴重心肺疾病的患者而言則是一種可靠的治療方式.日本的胃癌發生率居世界之冠，他們對早期診斷的普查工作特別努力，早期胃癌的病例約佔
1/3以上，而我國則不及1/10，值得我們努力改進。因此除了胃病患者外，40歲以上之中老年人，最好每年能定期接受胃鏡檢查.
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Case Discussion
繼續教育考題