Just Scratching the Surface: Intractable Nausea and Vomiting

Linitis plastica is an uncommon (<20% of all gastric cancers) and aggressive form of gastric cancer with a high rate of metastatic disease at the time of diagnosis and poor prognosis.We present a case of linitis plastica masquerading as peptic stricture in a young Hispanic woman. The diagnosis was delayed owing to sparing of the gastric mucosal layer by the malignancy.

A 42-year-old Hispanic woman was referred to the gastroenterology clinic by her primary care physician for heartburn, epigastric pain, intermittent nausea and vomiting, and 6.8 kilograms weight loss over the last 3 months. She did not have any significant past medical history. She reported that her maternal grandmother had “some kind of cancer.” She had never smoked and used alcohol socially. She used to work as a house cleaner.

Her vital signs and results of physical examination were within normal limits. Laboratory testing was significant for normocytic anemia (hemoglobin 11.5 g/dL, mean corpuscular volume 84.9 fL) and elevated lipase (71 IU/L; normal <60 IU/L) with normal electrolytes and renal and hepatic function.

An esophagogastroduodenoscopy (EGD) 3 days later demonstrated significant food residue in the gastric body, limited dilation of the stomach on air insufflation, and edema and erythema of the antral mucosa with a nonbleeding antral ulcer. Biopsies from the antrum showed nonspecific mucosal inflammation and interstitial edema without Helicobacter pylori infection, dysplasia, or malignancy. A computed tomography (CT) scan of the abdomen and pelvis was done for workup of antral mucosal edema 2 weeks later. It showed gastric outlet obstruction (GOO) with a circumferential soft-tissue thickening and mucosal hyperenhancement in the gastric antrum and pyloric canal. A diagnosis of benign peptic stricture was made, owing to the absence of any intra-abdominal lymphadenopathy. The patient was started on proton pump inhibitor therapy twice daily.

A follow-up EGD 4 weeks later showed a healing ulcer in the antrum. A large amount of food was again noted in the stomach that was ascribed to partial GOO from the antral stricture. The endoscope passed easily through the pylorus. Therefore, no endoscopic dilation was performed. She was referred to the surgery clinic for further evaluation. The surgeon requested an upper gastrointestinal series that was significant for a dilated stomach with a large amount of food, and luminal irregularity with narrowing of the gastric antrum. The patient declined surgical intervention initially. However, after 4 months of intermittent symptoms and additional 8.2 kilograms weight loss, she agreed to surgery.