CASE REPORT.
This unusual case is presented with the patient’s permission because she hopes this can further the care of others. She will remain anonymous as per standard protocol.
AN UNSUAL PRESENTATION.
A few weeks ago, a 24 y/o Haitian American female was admitted for c/o 15 lb weight loss over the previous 2 months, persistent nausea, vomiting, epigastric pain radiating to the back in a crescendo pattern. She had a history of iron deficiency anemia attributed to menometrorrhagia. She stated then that a few weeks prior, she was admitted at another institution for almost same c/o that had been present for quite a few months. She underwent an upper endoscopy that revealed a 1.5 cm gastric ulcer that was biopsied and was negative for H. pylori and malignancy. She was sent home on a PPI. It’s not clear if she took it as directed. She also happened not to have any medical insurance. Patient also mentioned that for previous few days leading up to coming to the ER, she had noted tarry stool. On physical exam, her vitals were stable, she was pale and had significant epigastric tenderness. Her lab results were significant for the following: hemoglobin of 6.8, MCV of 57.7, ferritin of 13. CT of the abdomen was significant for the discovery of lucent lesions throughout the spine and pelvis, raising the issue of metastasis. She was admitted and GI consultant proceeded to repeat EGD that revealed a 2 cm ulcer at the junction of the antrum and body of the stomach as well as severe gastritis and possible linitis plastica. The ulcer was biopsied. An oncologist also evaluated patient and a biopsy of one of the bone lesions was done. Both biopsies came back positive for adenocarcinoma of gastric origin, making this a stage IV presentation in a 24-year-old female. For the second time, the gastric biopsy was H. pylori negative. Once this result became available, patient was interviewed again and both parents who are alive, denied any family history of gastric cancer.
Patient had a stormy hospital course. She was extremely nauseated and could barely take anything by mouth. Zofran 6mg had to be administered around the clock Q 6hrs. She was in constant pain from the bone mets and she either had to be very drowsy from the opiates necessary to control the pain or be writhing in excruciating dolor. She received one cycle of chemo after insertion of a port and due to her anorexia and profound nausea, central hyperalimentation was started. The nausea and vomiting started abating with the addition of thiamine 100mg IV daily and Pyridoxine 100mg daily. Marinol didn’t seem to make much of a difference in improving her appetite. In addition to the above, she then had to suffer from opiates-induced severe constipation, acute depression because of the underlying diagnosis.
Zometa given once by oncologist caused sudden drop of her calcium and she became symptomatic with cramps. It was jarring to see a young person go through this agony. Her nausea, vomiting, anorexia, constipation, slowly but gradually improved to the point that the central hyperalimentation was discontinued and she was eventually discharged home.
Discussion. The appearance of linitis plastica is ominous; it’s a descriptive term of a rare cancer that distorts the mucosa and makes it difficult to absorb food1. This young patient belongs to the class of Gastric Cancer in Young Adults, GCYA. Li, Jian in an interesting review of the subject2 mentions the fact that the diagnosis of GCYA is found in 5% of cases of patients, and GCYA tends to present with an advanced state at the time of diagnosis, is very aggressive i.e., a high percentage of bone mets, which we see in our patient and is more common in females. However, there are other features that don’t seem to fit. For example, it’s more common in Asia, is overwhelmingly associated with H. pylori infection, has a hereditary bent, and is influenced using nicotine, alcohol. The oncologist taking care of the patient was musing the potential for doing genetic study, which itself is problematic since there is no family history of the disease and the very gory notion that an asymptomatic individual carrying a defective gene would be treated with prophylactic total gastrectomy.
This disease presenting in a such a young person is indeed rare, especially in a person not of Asian ethnicity3. Primary care physicians need be proactive in patients presenting with persistent symptoms not responding to therapeutic intervention (s).
References:
- Cancer.gov
- Li J. Gastric Cancer in Young Adults: A Different Clinical Entity from Carcinogenesis to Prognosis. Gastroenterol Res Pract. 2020 Mar 2;2020:9512707.
- Zhou F, Shi J, Fang C, Zou X, Huang Q. Gastric Carcinomas in Young (Younger than 40 Years) Chinese Patients: Clinicopathology, Family History, and Postresection Survival. Medicine (Baltimore). 2016:95(9):e2873.