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CASE REPORT
Year : 2013  |  Volume : 10  |  Issue : 2  |  Page : 91-94

Severe bone pain as first presentation of gastric malignancy


Department of Internal Medicine, Gastroenterology/Hepatology Unit, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication7-Dec-2013

Correspondence Address:
Samaila Adamu Alhaji
Department of Internal Medicine (Gastroenterology/Hepatology Unit), Bayero University Kano/Aminu Kano Teaching Hospital, PMB 3452, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-8540.122770

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  Abstract 

Gastric cancer still accounts for significant cancer mortality world-wide. It generally occurs at advanced ages in most parts of the world but reports in Nigeria so far indicates that gastric carcinoma is seen in younger ages. Most cases of gastric cancer present late; with weight loss, abdominal pain/swelling, anorexia, and vomiting with or without hematemesis. Presentation with bone pains is uncommon. We report a 23-year-old female Nigerian who presented with generalized bone pain with limitation of movement, use of non-steroidal anti-inflammatory drugs and recurrent hematemesis. She was resuscitated and further evaluation revealed; anemia, hypercalcaemia, and X-ray osteolytic lesions, suggestive of multiple myeloma. Bone marrow aspiration cytology however, showed heavy infiltration with clusters of abnormal cells suggestive of mucin secreting adenocarcinoma. Upper gastrointestinal endoscopy revealed gastric tumor, histologically confirmed to be a poorly differentiated adenocarcinoma. Gastric cancer typically presents late and in advanced stages. Typical symptoms may include, weight loss, abdominal pain, vomiting, and hematemesis. It may however present with metastasis to the bone and present with bone pains. It is recommended that evaluation of patients with bone pain should include upper gastrointestinal endoscopy especially, where anemia or upper gastrointestinal bleeding is co-existent.

Keywords: Bone pain, cancer, first, gastric, presentation


How to cite this article:
Mohammed TB, Alhaji SA, Muhammad BM, Kumo BA. Severe bone pain as first presentation of gastric malignancy. Niger J Basic Clin Sci 2013;10:91-4

How to cite this URL:
Mohammed TB, Alhaji SA, Muhammad BM, Kumo BA. Severe bone pain as first presentation of gastric malignancy. Niger J Basic Clin Sci [serial online] 2013 [cited 2021 Dec 2];10:91-4. Available from: https://www.njbcs.net/text.asp?2013/10/2/91/122770


  Introduction Top


Although the global prevalence of gastric cancer is declining, it is still the second most common cause of cancer-related death in the world, and it remains difficult to cure in even in developed countries, primarily because most patients present with advanced disease. [1],[2],[3]

Prevalence of gastric cancer is generally low in various parts of Nigeria, as well as other African countries. [4],[5],[6],[7] Previous report puts gastric cancer at 0.024% of all patients presenting for endoscopy over a 2 year period in Kano, Nigeria. [8] World-wide gastric cancer rates are about twice as high in men as in women and studies in Nigeria also show male preponderance. [4],[5],[6],[7],[8]

Gastric cancer occurs at advanced ages and most patients are elderly at diagnosis. The median age for gastric cancer in the United States is 70 years for males and 74 years for females, but reports in Nigeria so far indicates that gastric carcinoma is seen in younger ages with peak age of presentation from both Northern and Southern Nigeria being the 5 th decade of life. [4],[8] The gastric cancers that occur in younger patients may represent a more aggressive variant or may suggest a genetic predisposition to development of the disease.

Most cases of gastric cancer present late; with weight loss, abdominal pain/swelling, anorexia and vomiting with or without hematemesis. Presentation with bone pains is uncommon and in fact rare. [8] We present a case of gastric cancer in a very young Nigerian presenting with bone pains as first presentation.


  Case Report Top


A 23-year-old female Nigerian, presented with severe generalized bone pain worse on the back and hip joints for 3 months. She developed progressive painful limitation of movement 1 month into the illness and has been taking non-steroidal anti-inflammatory drugs (NSAIDs), which she was receiving from other hospitals. She presented to us with massive hematemesis on day of presentation. She has had 1 month history of recurrent mild hematemesis with melena stools. There was unquantified weight loss, no diarrhea, constipation or jaundice and no urinary symptoms. There was no epistaxis; no bleeding from any other orifice and her menstrual cycle was regular.

On examination, she was chronically ill-looking, markedly pale and wasted. Pulse was 120/min, regular, small volume, and blood pressure of 90/60 mmHg supine. She had significant bone and joint tenderness.

She was resuscitated with intra venous fluids, proton pump inhibitors, and blood transfusion without repeat hematemesis.

Full blood count revealed parked cell volume (PCV) 17%; platelets 86 × 10 9 /L, WBC 4.3 × 10 9 /L and blood film showed hypochromic red blood cells with dimorphic: Normocytic/microcytic picture. Her serum Ca 2+ was elevated (3.3 umol/L) but phosphate (1.3 mmol/L), urea, electrolytes, creatinine, fasting blood glucose, uric acid and urinalysis were normal. Liver function tests, serum proteins and clotting profile were also normal.

Blood group was A + and genotype AA. Human immunodeficiency virus screen, hepatitis B surface antigen and hepatitis C antibody were non-reactive.

Abdominal ultrasound and chest X-ray were normal but pelvic X-ray revealed osteolytic lesions with generalized osteopenia.

Initial diagnosis of multiple myeloma with NSAID induced upper gastrointestinal bleeding was entertained, but serum electrophoresis and urinary Bence Jones proteins were negative.

Bone marrow aspiration cytology showed; tri-linear bone marrow depression and no significant plasma cells. There was however heavy infiltration of bone marrow with clusters of abnormal cells, having open chromatin pattern and foamy vacuolated cytoplasm suggestive most likely of mucin secreting adenocarcinoma.

Upper Gastrointestinal endoscopy showed a huge fungating, friable gastric tumor [Figure 1], which was histologically confirmed to be a poorly differentiated intestinal type adenocarcinoma [Figure 2].
Figure 1: Endoscopic picture of gastric tumor

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Figure 2: Histology picture of the gastric tumor in Figure 1 showing adenocarcinoma

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Patient was managed conservatively with analgesics and proton pump inhibitors and her care was taken over by the general surgical team of the center; however, she deteriorated and died before any intervention could be offered.


  Discussion Top


Gastric cancer was once the second most common cancer in the world. In most developed countries; however, rates of stomach cancer have declined dramatically over the past half century. [1],[2] In the United States, stomach malignancy is currently the 14 th most common cancer.

Nevertheless, gastric cancer is still the second most common cause of cancer-related death in the world, and it remains difficult to cure even in developed countries, primarily because most patients present with advanced disease. Even patients who present in the most favorable condition and who undergo curative surgical resection often die of recurrent disease.

The American Cancer Society estimated that 21,130 cases of gastric cancer will be diagnosed in 2009 (12,820 in men, 8,310 in women) and that 10,620 persons will die of the disease.

In Kano, Nigeria endoscopic prevalence puts gastric cancer at 0.024% of all patients presenting for endoscopy over a 2 year period. [9] Generally, low prevalence is the trend in other parts of Nigeria as well as other African countries. [4],[5],[6],[7]

World-wide gastric cancer rates are about twice as high in men as in women and studies in Nigeria also show male preponderance.

Most patients are elderly at diagnosis, the median age for gastric cancer in the United States is 70 years for males and 74 years for females, but reports in Nigeria so far indicates that gastric carcinoma is seen in younger age as against that reported in the Western world. Peak age of presentation from both Northern and Southern Nigeria is the 5 th to 6 th decade of life. [3],[10] In fact the report from our hospital revealed that about half of the patients with gastric cancer were less than 50 years and this index case was just 23 years of age. [8]

The gastric cancers that occur in younger patients may represent a more aggressive variant or may suggest a genetic predisposition to development of the disease.

Most cases of gastric cancer present late, with weight loss, abdominal pain/swelling, anorexia, and vomiting. However, this patient presented atypically with bone pains and hypercalcaemia from bone metastases and the X-ray finding of punched-out osteolytic lesions makes the case a very close mimicker of multiple myeloma. However, the unexpected absence of plasma cells in the bone marrow, absence of Bence Jones proteins in the urine and normal serum electrophoresis ruled out multiple myeloma.

There has been very few reports of gastric malignancy presenting with symptoms referable to the bone and most of this were not as first presentation. [9],[11] Our patient's presentation was rather atypical considering the long duration of bone pains she had before hematemesis ensued. If she had not had hematemesis, she would have probably continued to be seen at peripheral hospitals where increasing doses of NSAIDs were being used.

Our patient had a fungating gastric mass with easy contact bleeding; however, the use of NSAIDs contributed to her presentation with massive upper GI bleeding. Although she did not have immediate endoscopy because of resuscitation, it is pertinent to stress that early endoscopy in all cases of upper gastrointestinal bleeding is essential even when the bleeding has stopped on conservative management as in our patient. The presentation was quite typical of NSAID induced upper GI bleeding, which commonly follows erosions and/or ulcerations and thus gastric cancer was not immediately entertained as a likely etiology especially considering her young age.

Tumor markers which can be very useful in evaluation of occult malignancy were not requested as it was no longer useful following the endoscopic confirmation of gastric primary tumor. Although abdominal computed tomography scan is a valuable investigation in staging of gastric tumor, but was not carried out in this patient because she already had a very advanced disease as at the time of diagnosis by virtue of bone and bone marrow infiltration. Our patient did not benefit from any intervention by the surgical unit that took over her management as she died shortly afterward while awaiting surgery. This is the usual trend in almost all cases of gastric cancer especially in developing countries because it is often detected very late. [4],[7] The increasing availability of endoscopy services in our tertiary institutions may help detect some cases early especially, where typical presentation with dyspepsia is seen in higher age groups.


  Conclusion Top


Gastric cancer typically presents late and in advanced stages. Typical symptoms may include, weight loss, abdominal pain, vomiting, and hematemesis. It may however present with metastasis to the bone and present with bone pains. It is recommended that evaluation of patients with bone pain should include upper gastrointestinal endoscopy especially where anemia or upper gastrointestinal bleeding is co-existent.

 
  References Top

1.Parkin DM. Global cancer statistics in the year 2000. Lancet Oncol 2001;2:533-43.  Back to cited text no. 1
[PUBMED]    
2.Parkin DM, Bray FI, Devesa SS. Cancer burden in the year 2000. The global picture. Eur J Cancer 2001;37:S4-66.  Back to cited text no. 2
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3.Oluwasola AO, Ogunbiyi JO. Gastric cancer: Aetiological, clinicopathological and management patterns in Nigeria. Niger J Med 2003;12:177-86.  Back to cited text no. 3
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4.Alatise OI, Lawal OO, Adesunkanmi AK, Agbakwuru AE, Arigbabu OA, Ndububa DA. Clinical pattern and management of gastric cancer in Ile-Ife. Nigeria. Arab J Gastroenterol 2007;8:123-6.  Back to cited text no. 4
    
5.Ajao O. Gastric Carcinoma in a tropical African population. E. African Med J 1982;59:70-5.  Back to cited text no. 5
    
6.Takyi HK. A review of cancer of the stomach as seen in Korle Bu Teaching Hospital. Ghana Med J 1972;11:133.  Back to cited text no. 6
    
7.Ogutu EO, Lule GN, Okoth F, Musewe AO. Gastric carcinoma in the Kenyan African population. East Afr Med J 1991;68:334-9.  Back to cited text no. 7
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8.Tijjani BM, Borodo MM, Samaila AA. Upper gastrointestinal tract cancers at endoscopy in Kano North-Western Nigeria. Niger J Med 2009;56:6-8.  Back to cited text no. 8
    
9.Hussain S, Chui S. Gastric carcinoma presenting with extensive bone metastases and marrow infiltration causing extradural spinal haemorrhage. Br J Radiol 2006;79:261-3.  Back to cited text no. 9
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10.Holcombe C, Babayo U. The pattern of malignant disease in north east Nigeria. Trop Geogr Med 1991;43:189-92.  Back to cited text no. 10
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11.Massarotti M, Ciocia G, Ceriani R, Chiti A, Marasini B. Metastatic gastric cancer presenting with shoulder-hand syndrome: A case report. J Med Case Rep 2008;2:240.  Back to cited text no. 11
[PUBMED]    


    Figures

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Abstract
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