Case History:

A 61-year-old male patient presented in the outpatient department of medicine in Capital Hospital Islamabad, complaining of severe epigastric pain that had been increased in intensity since last 15 days. The onset of pain was sudden, burning and pinching in character, aggravated by intake of food and relieved by strong painkillers and pain radiated to back. The patient also had low-grade fever since last 10 days and generalized weakness. Pain starts a few minutes after taking a meal. There was no history of dysphagia, melena, shortness of breath, cough, chest pain or discomfort, food regurgitation, vomiting, hematemesis, altered bowel habits and burning or difficult micturition. There was no significant past medical or surgical history. The patient was a non-smoker, had decreased appetite and sleep disturbance. There was no history of Diabetes mellitus, hypertension, heart diseases, asthma or cancer in the family.

On examination, his pulse rate was 76 and blood pressure was 130/90 mm of Hg. Abdominal examination revealed tender epigastrium (just below xiphisternum). Throat and rest of the systemic examination were normal.

Now the only complaint of the patient was severe epigastric pain that started after taking meal and the pain radiated to back. All the investigations were done.
WBC: 7700 per microliter
Hemoglobin: 13.7g/dl
Platelets count: 292000
BSR: 102mg/dl
ALT: 23 IU
Cret: 1.2
Urea: 28
Total Bilirubin: 1.0
S. Amylase: 77 U/L
S. Ca: 10.7 mg/dl
Serum Electrolytes. Normal
Ultrasound abdomen showed hepatomegaly and right renal cyst.
So investigation didn’t prove anything. After that Dr. Siddique Akbar Satti Decided to go for an upper GI endoscopy, thus patient was prepared and endoscopy was done and we got following pictures.
esophageal cancer endoscopy dr siddique akbar sattiesophageal cancer, dr siddique akbar satti
endoscopic view of esophageal growth by dr siddique akbar satti of capital hospital islambadtumor in esophagus, dr siddique akbar satti head department of medicine capital hospital
Courtesy Dr siddique akbar satti, esopgaeal cancer in endoscopyendoscopic view of esophgeal growth, by dr siddique akbar satti
These are the endoscopic pictures of the esophagus of the patient.
There is an irregular,non circumferential growth with evidence of mucosal friability,superficial ulceration and contact bleeding along the right lateral wall of the esophagus.The growth extends for a total length of 7cms.Starting 32cmc from incisor teeth.Multiple biopsies taken from the growth. Gastro esophageal junction and Z- line is clear
CT scan of the chest was done and Patient referred to surgery and oncology for further management.

Discussion

Oesophagal cancer presents with the symptoms of dysphagia, weight loss, chest pain or burning, indigestion and heartburn. Severe epigastric pain is not a typical symptom of the oesophagal problem. Severe epigastric pain that starts right after taking food raises the suspicion of some stomach problem such as acid peptic disease, acute gastritis, stomach ulcer and erosions etc. The epigastric pain that was radiating to back raises the suspicion of acute pancreatitis that was ruled out in this patient. There was no history of dysphagia,  hoarseness, coughing up blood, food regurgitation (very typical symptoms of oesophagal cancer), melena and chest pain. All other investigation came out normal, none of the symptoms was suggestive of some kind of oesophagal cancer or problem, yet upper endoscopy revealed a large growth in the oesophagus. Stomach, first and second part of the duodenum were normal. So this was an unusual presentation of oesophagal cancer with severe epigastric pain, weight loss and anorexia.

References:

Cancer Research UK: Symptoms of esophageal cancer, Url: https://www.cancerresearchuk.org/about-cancer/type/oesophageal-cancer/about/symptoms-of-oesophageal-cancer
accessed on 28:10:2014
Special Thanks:
Dr. Siddique Akbar Satti, Head Department of Medicine, Capital Hospital Islamabad, Pakistan
 
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