A 10-year-old Saudi girl was referred to our hospital with a complaint of progressive intermittent vomiting for 6 months. The vomiting was projectile of semidigested food content and almost always after meals. It was associated with nonspecific nonradiating epigastric pain, undocumented weight loss, progressive fatigability, and bone aches. There was no history of fever, loose bowel motions, or hematemesis. Her family history was negative for tuberculosis, peptic ulcer diseases, or gastric carcinoma. At physical examination, she was emaciated, sick, pale, and severely dehydrated. There were no palpable pathologic lymph nodes, jaundice, or skin rash. She was afebrile with pulse rate 110 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 90/60 mmHg. Her weight was 18.9 kg (<5th percentile for age and sex) and height 137.5 cm (on the 50th percentile). Local examination revealed a soft and lax abdomen with fullness at epigastrium (Figure 1) with no palpable masses, organomegaly, or ascites. Another systemic examination was unremarkable.
Initial laboratory investigations showed hemoglobin 14 gm/dL, white blood cell count 9.2 x 109/L, platelet count 459 x 103/mm3, erythrocyte sedimentation rate 30 mm/hr (normal, 0-10 mm/hr), and normal peripheral blood smear. Her blood gases revealed pH 7.59, PCO2 50 kPa, and HCO3 55 mmol/L. Other laboratory workup showed hyponatremia (122 mmol/L), hypokalemia (1.87 mmol/L), hypochloremia (62 mmol/L), hyperuricemia (418 mmol/L), and elevated urea (13 mmol/L) and creatinine (69 mmol/L). Her liver function test, serum amylase/lipase and lactate dehydrogenase levels were all normal. At this stage, the clinical diagnosis was gastric outlet obstruction. After correction of dehydration and electrolyte imbalance and establishment of total parenteral nutrition, she underwent barium meal which confirmed the clinical impression of gastric outlet obstruction and in addition showed a crater of an ulcer at lesser curvature (Figure 2).
Ultrasound of abdomen revealed marked thickening of antral wall (12 mm in diameter) and pyloric channel (Figure 3) and moderate amount of fluid within the pelvis. Upper gastrointestinal endoscopy showed a markedly erythematous, fragile and erosive mucosa at lower esophagus, a markedly thickened antral mucosa occluding the pylorus, and a clean base ulcer 2 centimeters x 1.5 centimeters at the lesser curvature of the stomach (Figure 4). The narrowed antrum and pylorus underwent balloon dilatation; afterwards, it was possible to pass pediatric size scope (8.6 mm) through the pylorus down to the duodenum which looked normal and nasojejunal tube was passed through for continuous enteral feeding. The esophageal biopsy showed reflux esophagitis, and the antral biopsies revealed active chronic Helicobacter pylori gastritis grade IV with no metaplastic changes. The biopsies obtained from the edge of the gastric ulcer demonstrated poorly differentiated signet-ring-cell adenocarcinoma (Figure 5). For staging purposes, abdominal CT scan was performed. It revealed marked thickening of antral wall (18 mm in diameter) and pyloric channel and hypodense soft tissue densities at the celiac axis suggestive of celiac lymphadenopathy, and no definite signs of infiltration either of the liver or pancreas could be visualized. CT scan of the chest showed normal lungs, heart, and pleural spaces and no evidence of metastatic lesions or lymphadenopathy. Bone scan study was negative for evidence of metastases.
The child underwent exploratory laparotomy to evaluate for resectability of the gastric tumor. There were small metastases to the liver, head of pancreas, and mesenteric lymph nodes and aspirate from ascitic fluid revealed malignant cells. Therefore, the gastric carcinoma was deemed unresectable and a gastrojejunostomy tube was placed for enteral nutrition and gastric decompression. The patient received chemotherapy consisting of cisplatin, 5-fluorouracil, and methotrexate. Followup CT scan of abdomen showed no response, so the patient was put on palliative care including analgesics. Unfortunately, she died few months after diagnosis due to advanced carcinoma.