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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 1  |  Page : 52-54

An unusual case of limited gastric linitis plastica in a Nigerian: A review of clinical, endoscopic and radiologic diagnostic aspects


1 ReMay Consultancy and Medical Services, Ikeja, Lagos State, Nigeria
2 Department of Radiodiagnosis, College of Medicine, University of Lagos, Lagos, Nigeria

Date of Submission28-Jun-2020
Date of Decision27-Jul-2020
Date of Acceptance04-Aug-2020
Date of Web Publication4-May-2021

Correspondence Address:
Dr. Aderemi O Oluyemi
ReMay Consultancy and Medical Services, Ikeja, Lagos State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_21_20

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  Abstract 


Linitis plastica is considered to be one of the rarer types of gastric cancers. The involvement of only the fundus is the least common of the morphologic variants. This limited type is hardly ever documented among sub-Saharan African patients in scientific literatures. This case report presents one such unique case. Using unique attributes of this case's presentation, this article reviews clinical, endoscopic and radiologic aspects of the diagnosis of this unusual malignant entity.

Keywords: Endoscopic ultrasound, gastric fundus, hiccups, linitis plastica


How to cite this article:
Oluyemi AO, Adeyomoye AO. An unusual case of limited gastric linitis plastica in a Nigerian: A review of clinical, endoscopic and radiologic diagnostic aspects. Niger J Basic Clin Sci 2021;18:52-4

How to cite this URL:
Oluyemi AO, Adeyomoye AO. An unusual case of limited gastric linitis plastica in a Nigerian: A review of clinical, endoscopic and radiologic diagnostic aspects. Niger J Basic Clin Sci [serial online] 2021 [cited 2021 Jun 23];18:52-4. Available from: https://www.njbcs.net/text.asp?2021/18/1/52/315408




  Introduction Top


Linitis plastica (LP) was first described in scientific literature by Brinton in 1859 and is a form of adenocarcinoma of the stomach characterised by infiltration of the malignant cells into the submucosa and walls of the stomach.[1] The resultant marked thickness and leather water-bottle appearance of an affected stomach is what earned it the name 'linitis plastica'. Morphologically, the cancer type can be divided into the limited and generalised forms based on the extent of the involvement of the gastric anatomical regions.[1],[2] The limited form is most commonly present in the antral region and is only rarely described being limited to the fundus.[1],[2] This article seeks to document one such rare occurrence from our locality.


  Case Report Top


A 75-year-old retired Nigerian soldier with a significant history of smoking (>15 pack years for 20 years) presented with a 24-h history of altered sensorium following a 5-day history of hiccups and yellowness of the eyes. He had, however, quit smoking more than 15 years before presentation. A 2-week history of generalised weakness, easy satiety and loss of appetite was noted to precede his index complaints. The patient had a background history of diabetes mellitus but had, however, never been diagnosed with liver disease previously.

The persistent hiccups he presented with were described as distressing as they were continuous and only partially relieved with sleep. There was no history of abdominal pain, but the patient had discomfort that was localised to the left upper aspect of the abdomen and this had been present for 4 weeks before presentation.

The findings on the examination included altered sensorium as the patient seemed to drift in and out of sleepy state, and he also had a flapping tremor. There was deep conjunctival icterus, generalized pruritus and persistent hiccups whenever he was fully awake. Peripheral stigmata of chronic liver disease were absent. On examination, the abdomen was swollen, and the patient had an enlarged, smooth and tender liver.

Report of plain abdominal X-ray done indicated a reduction in distension in the upper half of the stomach. An abdominal ultrasound showed multiple peritoneal masses in the upper part of the abdomen. The liver was enlarged and showed dilatation of the intra- and extra-hepatic ducts. A computed tomography (CT) of the abdomen was requested and showed infiltrative thickening of the fundus of the stomach with irregular mucosal lining indicative of malignancy [Figure 1]. The liver was enlarged and showed dilatation of the hepatic ducts [Figure 2]. Multiple enlarged intraabdominal lymph nodes were seen. The superior mesenteric group of nodes was noted to be compressing the distal common bile duct with resultant dilatation of the hepatic ductal channels proximal to this point [Figure 2] and [Figure 3].
Figure 1: The markedly thickened gastric walls with irregular mucosal outline and enlarged gastrohepatic group of lymph nodes

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Figure 2: Dilated intrahepatic ducts (arrows) due to compression of the common hepatic duct

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Figure 3: The enlarged superior mesenteric group of lymph nodes (arrow) compressing the common hepatic duct and responsible for the dilated intrahepatic ducts in Figure 2

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At gastroscopy, the mucosal lining of the fundus had characteristic diffusely thickened folds. There was notable lack of full distensibility of the gastric cavity in spite of sustained attempts at air insufflation thus the cavity here appeared markedly narrowed. This abnormal appearance was restricted to the fundus as the mucosa further distally was normal. The use of either diathermic snare or endoscopic 'forage' as biopsy techniques to obtain larger and deeper histologic samples were considered but not chosen because they carried a substantial risk of complications, particularly haemorrhage and perforation in the index patient. Hence, the 'turn-and-suction' endoscopic biopsy technique was deployed with the regular biopsy forceps to obtain the tissue. Histology showed poorly differentiated adenocarcinoma with signet ring cells. A diagnosis of LP (limited) of the gastric fundus with distant metastasis and obstructive jaundice secondary to metastatic lymph node infiltrates was made. Unfortunately, the above-detailed results were assembled within a 2-week period reflecting the limitations of our resources-constrained environment, and the patient died shortly after presentation.


  Discussion Top


LP is characterised macroscopically by diffuse rigidity of the gastric wall and thick mucosal folds which results from diffuse adenocarcinomatous (poorly differentiated/anaplastic) infiltration of the deeper layers of the of the stomach.[2] It is thought to be one of the rarer forms of intestinal cancers, and the most common organ involved is the stomach. The reports of this condition in sub-Saharan African patients are sparse.

Based on the extent of the involvement of the gastric regions, the morphology is divided into the limited and diffuse types. When limited, gastric LP is most commonly present in the antral and pyloric regions-the fundus is rarely ever the solely affected region.[3]

Notably, in our patient's clinical presentations were the presence of persistent hiccups and icterus. Hiccups (medical term 'singultus') are repeated spasms of the diaphragm followed by sudden closure of the glottis and pathological hiccups could be either persistent (episodes lasting more than 48 h) or intractable (episodes lasting more than one month).

The pathogenesis of this often brief and self-limiting reflex is not fully understood, but we surmise that in the case of this patient, it was due to direct irritation of the vagus or phrenic nerves by this infiltrative tumor-these nerves constitute the afferent pathway of the hiccups reflex arc.[4] The treatment for this kind of malignancy-related hiccups will require surgical removal of the offending lesion and for the inoperable ones may require the use of butyrophenones (such as haloperidol) because this debilitating symptom may, as in our patient, be refractory to the use of phenothiazines-like chlorpromazine.[4]

Lymph node metastasis is common at the diagnosis in LP and appears to portend worse prognosis. The presence of lymph node involvement is considered a crucial prognostic factor as it is thought to contribute significantly to the markedly lowered survival of these patients compared with those with other types of gastric cancer.[2] Some phenomena that can result from such lymphadenopathies include obstruction of the biliary pathways. Enlargement of the superior mesenteric group of lymph nodes in this index case had led to the obstruction of the hepatic biliary system with consequent jaundice in our patient.

It must be stressed that the mucosa is often, to the eye of the endoscopists, spared as the cancer cells infiltrate the submucosa tissue without either ulceration or elevation on the mucosal surface particularly in the early phase.[2] The case presented highlights the problem of reduced sensitivity of regular biopsy samples, which can be as low as 33%.[5] This sometimes results in delayed diagnosis and worsened patient prognosis. Thus, the use of the 'turn-and-suction' endoscopic biopsy technique in this particular instance just to increase the chances of positive yield.[6] It is therefore welcome that radiology has been shown to be an invaluable tool in the diagnosis and patient management.

Radiology has been suggested to be at least as sensitive as or superior to endoscopic examination in correct tumor localisation and diagnosis of LP.[7] CT is an important complimentary imaging technique to detect this and other types of gastric carcinomas.[7],[8],[9] It is also used to determine the stage and spread of a gastric carcinoma. This information is vital in deciding between palliative surgery and curative radical surgery (i.e., identifying patients who would not benefit from radical surgery). In addition, CT is used to monitor a patient's response to treatment.[8] The more recent introduction of endoscopic ultrasonography (EUS) into clinical armamentarium has been a true game changer.[10] The lesions have now been described in more ultrasonographic details and EUS can be used in a more targeted way to fetch superior yield samples, detail the extent of disease invasion into the stomach wall, describe the possible extent of lymph nodal invasion, and even obtain lymph node samples.[9] Sadly, this is not available in our country as yet.

In the case of our patient, the diagnosis was based on the features on endoscopy, supported by CT findings and histological assessment of endoscopic biopsies.


  Conclusion Top


The report has documented a case of an elderly Nigerian with the uncommon presentation of the limited form of gastric LP. We have also used the case to highlight relevant clinical, endoscopic and radiologic aspects to the diagnosis of this uncommon malignant, gastric disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Brinton W. The Diseases of the Stomach, with an Introduction on its Anatomy and Physiology being Lectures Delivered at St. Thomas's hospital. London: J. Churchill; 1859.  Back to cited text no. 1
    
2.
Endo K, Sakurai M, Kusumoto E, Uehara H, Yamaguchi S, Tsutsumi N, et al. Biological significance of localized Type IV scirrhous gastric cancer. Oncol Lett 2012;3:94-9.  Back to cited text no. 2
    
3.
Negreanu L, Assor P, Bumsel F, Metman EH. An endoscopic view in gastric linitis. A case report. J Gastrointestin Liver Dis 2007;16:321-3.  Back to cited text no. 3
    
4.
Kolodzik PW, Eilers MA. Hiccups (singultus): Review and approach to management. Ann Emerg Med 1991;20:565-73.  Back to cited text no. 4
    
5.
Maeda E, Oryu M, Tani J, Miyoshi H, Morishita A, Yoneyama H, et al. Characteristic waffle-like appearance of gastric linitis plastica: A case report. Oncol Lett 2015;9:262-4.  Back to cited text no. 5
    
6.
Levine DS, Reid BJ. Endoscopic biopsy technique for acquiring larger mucosal samples. Gastrointest Endosc 1991;37:332-7.  Back to cited text no. 6
    
7.
Park MS, Ha HK, Choi BS, Kim KW, Myung SJ, Kim AY, et al. Scirrhous gastric carcinoma: Endoscopy versus upper gastrointestinal radiography. Radiology 2004;231:421-6.  Back to cited text no. 7
    
8.
Varla H. Gastric Carcinoma Imaging. Available from: http://emedicine.medscape.com/article/375384-overview. [Last updated on 2015 Nov 13; Last accessed on 2020 Jun 28].  Back to cited text no. 8
    
9.
Morgant S, Artru P, Oudjit A, Lourenco N, Pasquer A, Walter T, et al. Computed tomography scan efficacy in staging gastric linitis plastica lesion: A retrospective multicentric French study. Cancer Manag Res 2018;10:3825-31.  Back to cited text no. 9
    
10.
Liu Y, Chen K, Yang XJ. Endoscopic ultrasound-guided fine-needle aspiration used in diagnosing gastric linitis plastica: Metastatic lymph nodes can be valuable targets. J Gastroenterol Hepatol 2019;34:202-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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