Famous Patients, Famous Operations, 2003 - Part 1: The Case of the Soldier with Epigastric Pain

Albert B. Lowenfels, MD

Disclosures

February 19, 2003

Introduction

A 52-year-old male professional soldier presents with a chief complaint of epigastric pain and vomiting (following intermittent vomiting [with occasional blood in vomitus] of several months' duration and abdominal pain), decreased appetite, and anorexia. Other complaints include frequent headaches, oral ulcerations, weakness and coldness of the lower extremities, cough, generalized fatigue, insomnia, and occasional attacks of dysuria. He has had no prior illnesses or hospitalizations.

He drinks wine and/or spirits daily with meals, is a nonsmoker, is married with several children, and has traveled extensively in Asia, Europe, the Near East, and North Africa.

His father died at age 38 of suspected gastric cancer. This may have been the cause of death for his sister and other family members as well. His mother died at age 86, presumably of natural causes.

The patient is short in stature, somewhat obese, and in obvious distress. His pulse is rapid and irregular, and he is dyspneic and somewhat drowsy. His skin and conjunctivae are yellow, and he has bilateral gynecomastia and diminished body hair. His liver is enlarged and tender and he has moderate pitting edema of his extremities.

The patient's abdominal pain persisted during the last 2 months of his life. About 2 weeks prior to his death, he developed persistent, severe thirst, hiccoughs, and frequent vomiting, which on several occasions contained dark and bright red blood. He had great difficulty ingesting food and became increasingly weak. Prior to his death he had a large bloody stool, became hypotensive, and died. An autopsy was performed.

Based on the clinical findings, which of these diagnoses is the least likely?

  1. Peptic ulcer

  2. Gastric cancer

  3. Cirrhosis of the liver

  4. Chronic pancreatitis

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If confronted with a similar patient, initial procedures likely to have a high yield of relevant information are:

  1. Liver function tests and upper gastrointestinal (GI) endoscopy with biopsy

  2. Endoscopic retrograde cholangiopancreatogram and computed tomography (CT) scan of the brain

  3. Colonoscopy and barium swallow

  4. CT scan of abdomen and barium enema

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Who is the mystery patient?

  1. Dwight Eisenhower

  2. Julius Caesar

  3. Napoleon Bonaparte

  4. Alexander the Great

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