By Tedler D. Depaynos, MD
The 74 years old male patient lives near a dam where their main livelihood is raising fish called “tilapia”. For the past few months, he has been experiencing “hyperacidity” after eating as described by his daughter. She bought him “Maalox” from time to time when she goes to the city to sell some of their products which gave him temporary relief.
After some time, the patient started complaining that his stomach easily gets full and there were times when he insists on eating some more because of “hunger”, he sometimes vomits. At one time it was noticed that his vomitus was with fresh blood. It was then that the patient was observed to be getting “pale”. Because of daily prolonged exposure to the sun which gave him a darker complexion his gradual “paleness” was never noticed. When asked if he has been passing out blood in his stools, he answered that from time to time his stools appeared “black”. Actually, it was during a gathering when a relative from another barangay whom they have not met for quite some time who noticed him to be “pale’. His daughter got then the impression that perhaps he has a “bleeding peptic ulcer” so that he was finally brought to a young MD whom they heard to be a townmate who was being geared to run for a political position.
On routine examination, the patient was obviously anemic. There was slight tenderness at the epigastrium and when a naso-gastric tube (NGT) was inserted into his stomach, dark blood was aspirated. A routine abdominal ultrasound was done and a “vague distal stomach mass” was noticed. There were also at least “3 small nodules” seen in the pancreatic area. Impression then was “distal gastric tumor” and he was referred to a Gastro-enterologist MD for esophago-gastro-doudenoscopy. Meanwhile blood transfusions were given to correct the anemia and hyperalimentation thru his IV was given.
A huge bleeding tumor was visualized at the distal stomach blocking the exit to the duodenum and the initial impression by the Gastro-enterologist MD was malignancy just by the looks. This was confirmed a week later with the final biopsy results. The pancreatic nodules were interpreted as metastasis and although the chest x-rays were essentially normal, a 4th stage malignancy was the impression. The Gastro-enterologist MD then verbalized that “hyperacidity” may be the initial manifestation of gastric Ca especially in the elderlies so that he advised that gastro-endoscopy should routinely be done in these age group especially if they have gastric discomforts or complaints for possible early diagnosis. In general, early stage Ca may have a chance of complete treatment.
He was later referred to a Surgeon MD who recommended a possible by-pass procedure where the stomach proximal to the tumor would be connected directly to the small intestine to by-pass the obstruction. At least the patient could enjoy eating his food and would be relieved of his “gastric fullness”.
When the children were told privately that their father is with a 4th stage gastric cancer, however, they developed negative thoughts that their father should undergo surgery especially when the procedure was explained that it was for palliative purposes only and it would not cure the disease. Aggressive surgery was no longer entertained. Besides, with the age of the patient and his condition that he has not been nourished for quite some time, they feared that he may not be able to undergo the surgery and even just the anesthesia. They consulted their other relatives and finally decided to bring home their father.
At home, the children planned to butcher 1 or 2 pigs and invite their other relatives and friends for their father to meet for they know he will not be staying long. The Surgeon just smiled because if the pigs would not be available, they would be cooking basins full of “tilapia”.