Yellow discolouration

Saturday, August 21, 2010

The pathologist reported

Sections show fragments of gastric mucosa with sheets and nests and occasional glands of malignant epithelial cells invading the stroma. The tumour cells are pleomorphic, have increased N/C ratio, vesiculer nuclei and eosinophilic cytoplasm. Abundant mitotic figures are seen.

Impression: Adenocarcinoma, poorly differentiated, infiltrating
This is an elderly woman in her seventies, who was warded 4 months ago with the chief compliant of yellow discoloration of her eyes and skin. I remember this particular patient vividly as she gave the medical team a hard time figuring out what is wrong with her.

When she was admitted, she was grossly jaundice. It wouldn't be difficult to spot her in a sea of people. The semester one student nurses were pretty curious with her presentation and some of them asked me what's wrong with her.

It's pretty simple when you have a patient presenting to you with jaundice which is actually yellow discolouration of the mucous membrane and skin due to excessive bilirubin deposition. In our Malaysian setting, an underlying liver pathology/gall stone disease is usually the culprit.

However, upon detailed history taking, we couldn't elicit anything related to an underlying chronic liver disease. No weight loss, appetite was fine either. Crepitations at both lung bases were picked up and the legs were minimally edematous as well. She has no risk factors of viral hepatitis infection but of course a full jaundice workup was done including hepatitis serology.

An ultrasound was subsequently ordered to look for evidence of liver cirrhosis that could explain her presentation. I scratched my head when the report came back, everything was fine other than the enlarged lymph nodes compressing the porta hepatis. Liver was homogenous in terms of echogenicity, no evidence of cirrhosis.

To cut the long story short, a full battery of investigations were performed and we finally hit the jackpot when an OGDS found a fungating mass at the body of the stomach. A biopsy was taken and the result as mentioned above. Bile flow was obstructed due to external compression by the enlarged lymph nodes. Prognosis was not good. Management was then to relieve the obstruction by stenting, the rest are just palliative.

I followed her up for almost two and a half weeks, trying to understand the disease progression. Every afternoon before lunch time, she'll definitely ask me whether I've had my lunch. And if I say no or later, she will start lecturing me on how I should take care of my own health, and how eating late is bad for health. She was a very cheerful lady and even the student nurses enjoyed chit-chatting with her. They call her "po po"(grandma). After the stent was put in, she was allowed to be discharged

Today while I was doing my groceries in Giant, I bumped into her daughter. We started talking and I asked about po po. "She passed away 2 weeks ago, in peace, without any pain" her daughter said. " Thanks for asking doc" she added.

I can't remember her exact full name. But other than that, I can remember every single thing she told me before she passed away. I spent quite some time telling stories, listening to stories, laughing with a woman who would not survive the year.

I do hope she's doing fine up there, surrounded by lovely people!