GASTROENTEROLOGY #8

DISCHARGE SUMMARY
The patient, a 43-year-old white man, a chronic alcoholic with advanced Cirrhosis and
Hiatus Hernia develop Distoesophageal Stenosis. An acute attack of dysphagia that lead
to hematemesis. The patient will began to lose weight ten months ago and five months
later, his abdomen began to swallow and quickly regain the 30 pound he had loss. He
had no dysphagia, no retanize bleeding. The day before, he was first examined he
suddenly became unable to swallow while eating lunch. He choked then coughed,
vomited hard and then brought up a cup full of fresh blood. Examination upon
hospitalization showed modern chronic illness, but no apparent acute problem at the
moment. There had been no further bleeding. The vital signs are normal. There were
classical signs of Alcoholic Cirrhosis, hepatomegaly, spider angioma, and muscle wasting
above the shoulders and zigoments.
LABORATORY FINDINGS: two respiration of the stomach showed no blood. The
initial hemoglobin was 12 g and hematocrit=38. The serum alkaline phosphotase was 17
units and serum bilirubin 2mg.
X-RAY STUDIES: Upper gastrointestinal study a wide interpreted there are showing a
small direct Hiatus Hernia, Distoesophagitis, and a low grade esophageal strictures
secondary to Esophagitis. Esophageal varices could not be demonstrated except for hiatus
hernia, the stomach and the duodenum were considered normal.
HOSPITAL TREATMENT: The day follow hospitalization is seen in gastroscopy wide
screening lab. Direct Hiatus Hernia and Esophagitis were confirmed. Varices were not
found. There was no esophageal stricture, instead the distal esophagus seems soft and
permitted easy passage of the 10 mm esophoscope. A 6x5 millimeter irregular ulcer was
found at the hyperemic mucosa just above the esophagastric junction. There was no
white lesion.
PATHOLOGISTS REPORT: Esophageal biopsies specimens contain the carcinoma.
The gastroscope examination showed that metastasis scattered over a finely morphic
cirrhotic liver.
FINAL DIAGNOSES:
1. Primary carcinoma of the herniated gastric chordia with the extension to the esophagus
and metastasis.
2. Alcoholic Cirrhosis.
3. Hiatus Hernia.
4. Uncomplicated Esophagitis.