Presented by:

Sir Salimullah Medical College

37th Batch (Roll: 115-124)

Particulars of the patient

Name : Md. Monir Hossain

Age : 18 yrs

Sex : Male

Marital status : Unmarried

Religion : Muslim

Occupation : Student, Diploma of computer hardware

Present Address : Satrauza, Mitford, Dhaka.

Permanent Address : Ramgonj, Lakkhipur.

Date of admission : 05/11/2012

Date of examination : 03/12/2012

Chief Complaints:
1.

Pain on the upper mid abdomen for 1

yrs.

2.

Vomiting for 1 year which was

exaggerated for the last 1 months.

History of Present Illness :

According to the statement of the patient, he was free
from Above symptoms about 1 year back. Then he
developed pain in the upper mid abdomen which was
mild, burning in nature, relieved by taking food and antiulcer medications with episodic occurrence.
About one year back he developed vomiting after taking
food. Vomiting was non-projectile and once daily at first;
later became twice daily, projectile, bitter in taste,
contained food particles taken earlier in the day.

History of Present Illness

(Cont.) :
On consulting the local doctor 8months back, patient
started on anti-ulcer medication (Esomeprazole) and
vomiting stopped for 3 months. Then vomiting again
started 4 months back, which was exaggerated,
about 3-4 times daily, about 1 months back.
One month back patient noticed swellings that moved
about the abdomen after taking meal, from left to right
in the upper abdomen. Patient has mild constipation,
his bladder habit is normal. Now he has come to this
hospital for better management.

History of Past Illness:

Patient had frequent dyspepsia about 1 year
back. Patient is non-diabetic, normotensive,
and non-asthmatic. No history of any
operation, or significant trauma was given.

Treatment History:
Patient was treated with PPI (Esomeprazole)
for about 8 months. No other treatment was
administered.

Family History:
Nothing contributory was found.

Personal history:
No history of smoking or alcohol intake.
Diet habit is normal. Lives in semipaka tin shed
house.
Sanitation is satisfactory and drinks supplied
water.

Immunization History:
Fully immunized as per EPI schedule.

Allergic History:
Nothing significant

General Examination
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Appearance
Body build
Nutrition
Decubitus
Pallor
Jaundice
Cyanosis
Clubbing
Koilonychia
Leukonychia
Oedema
Dehydration

:
:
:
:
:
:
:
:
:
:
:
:

Ill looking
Average
Undernourished
On choice
Mild (+)
Absent
Absent
Present
Absent
Absent
Absent
Absent

General Examination
13.
14.
15.
16.
17.
18.
19.
20.

Pulse
Blood Pressure
Temperature
Respiration
Hair distribution
Lymph Node
Neck Vein
Thyroid Gland

: 75 beats/min (Regular)
: 100/75 mm Hg
: Not raised
: 20 breaths /min
: Normal male pattern hair distribution
: Accessible lymph nodes not palpable
: Not engorged
: Normal

Alimentary System
Examination

INSPECTION
1. Shape : Flat
2. Flanks : Not full
3. Umbilicus : Inverted And Central in position
4. Visible vein : Absent
5. Visible Pulsation : Absent
6. Visible peristalsis : Peristalsis is visible in the epigastric
region moving from left to right.
7. Scar marks : None
8. Visible swelling : Absent
9. Hernial Orifices : Intact

PALPATION
a) Superficial palpation :
1. Local temperature : Normal
2. Rigidity and muscle guard :Absent
3. Any Pulsation : Absent

b) Deep palpation and organ palpation :

Tenderness: Absent.
Lump : No lumps felt.
Liver : not palpable
Gall bladder : Not palpable
Spleen : Not palpable
Kidney : Not pulpable

PERCUSSION
a) Percussion note : Tympanatic
b) Shifting dullness : Absent

AUSCULTATION
1. Bowel sound : Present & normal
2. Succussion Splash: Present

AUSCULTO-PURCUSSION
Greater curvature of the stomach was normal in position.

PER-RECTAL EXAMINATION :
Not done

OTHER SYSTEMIC EXAMINATIONS:

Revealed no other abnormality.

Salient Features
18 yrs old male patient Md. Monir Hossain hailing from
Ramgonj, Lakkhipur was admitted at this hospital with
the complaints of burning epigastric pain for 1 yrs
and vomiting for the last 1 year which has worsen
since last 1 months.
According to the statement of the patient, he was
reasonably well about 1 year back. Then he
developed pain in the epigastric region which was
mild, burning in nature, relieved by taking food and
anti-ulcer medications and was episodic in occurrence.

Salient Features (Cont.)

About one year back he developed vomiting after taking
food. Vomiting was non-projectile and once daily at first;
later became twice daily, projectile, bitter in taste,
contained food particles taken earlier in the day. No
history of blood in the vomit.
On consulting the local doctor 8months back, patient
started on anti-ulcer medication (Esomeprazole) and
vomiting stopped for 3 months. Then vomiting again
started 4 months back, which was exaggerated, about 34 times daily, about 1 months back.

Salient Features (Cont.)

Patient has good appetite, no fullness of abdomen and no
significant weight loss or wasting. No history of melena
(black tarry stool). Patient has mild constipation, his bladder
habit is normal.
On general examination patient was ill looking,
undernourished with mild pallor (+) and clubbing. No
accessible lymph nodes were palpable.

On systemic examination patient had visible peristalsis in

the epigastric region moving from left to right. No lump was
felt. On auscultation, succession splash was heard. All
other findings were normal.

DIAGNOSIS

PROVISIONAL DIAGNOSIS :
Gastric Outlet Obstruction Due to;
Pyloric stenosis secondary to peptic
ulceration.
Differential Diagnosis:
Gastric carcinoma (Common)
Pancreatic Carcinoma,
GIST (Gastro-Intestinal stromal Tumor)
Adult Pyloric stenosis (rare),
Congenital duodenal webs (rare).

INVESTIGATIONS
Routine Investigations:

CBC : Hb% - 12.1gm/dl

Total RBC count - 4.2 million/l
Total WBC count - 8,600/cumm
Total platelet Count - 240,000/cumm

ESR : 72 mm in the 1st hour

Serum Electrolyte :

Normal (as per report)

Blood sugar : 5.2 mmol/L (Normal)

Diagnostic Investigations

X-Ray :
Straight x-ray chest
AP view on errect
posture revealed no
abnormality or
deformity.

Ultrasonogram:
Normal study, no
abnormality was
detected.

Barium meal X-Ray:

(The report)

Barium meal X-Ray (Cont.) :

Barium meal X-Ray (Cont.) :

(Narrowing)

CT Scan :

Stomach : Appears to be distended in size.

Duodenum : Distal part of descending loop of

duodenum not well outlined with contrast
Possibly narrowed (Endoscopy please).

Pancreas : Normal in size, shape, position &

tissue density. No evidence of annular pancreas.

Liver : Normal in size with uniform tissue density.

Gall Bladder : Normal in

size & shape. Lumen clear.

Billiary Tree : Not dialated.

Spleen : Normal in size &

tissue density.

Kidney: Both kidneys are

normal in size, shape &
excretion of contrast
material.

Endoscopy :
Oesophagus :
Mucosa contains no lession, lumen appears
normal, no varix seen.
Stomach :
Mucosa covering cardia, fundus, body &
antrum seem normal. Pylorus is normal.
Duodenum :
The bulb is grossly deformed. An ulcer is
seen. The channel is narrowed. The
endoscope could be passed into the postbulbar area with moderate effort.

Comment:
CHRONIC DUODENAL ULCER WITH
GASTRIC OUTLET OBSTRUCTION.

Confirmatory Diagnosis
Gastric Outlet Obstruction Due to;
Duodenal ulceration & stenosis.

Treatment
Patient was treated surgically by
performing a;

SIMPLE GASTRO-JEJUNOSTOMY

Mid line incision on the upper abdomen

STOMACH

Pancreas
Narrowing

Stomach & intestine held by gastro-jejunostomy clump and being sewn

togather.

OOPPSSS
This is Embarrassing

During the operative procedure surgeon found

several lymph nodes to be enlarged Being
curious he took a lymph node for biopsy..

Guess what?? The biopsy revealed that the

ulcer was in fact a tuberculous ulcer.

Patient had MT test done previously but MT

test showed only 5mm of induration on the 3rd
day.. So, TB was ruled out initially. But turns
out the diagnosis was TB all along..

So, what did we learn from

it??
In Bangladesh, EVERYTHING IS TB.. :@