CASE HISTORY

In 1934 patient first complained of gastric symptoms. He then had pain 1 1/2 hours after meals relieved by  alkalis. The same year he had acute appendicitis and was operated. He was well for 8 months and then his symptoms returned. 1936: posterior gastro-jejunostomy was carried out. At this operation he was found to have a large active duodenal ulcer. He was well again for a few months but was re-admitted in  1937 with a mild attack of melaena. He was treated medically for 1 month and his symptoms subsided. After this he was well for 6 years ie, until 1943, when he again started to have intermittent attacks of abdominal pain. These continued until 1949. In Jan 1949 he was again admitted on account of another attack of melaena.  Gastroscopy showed a hypertrophic gastric mucosa and a gastro-enterostomy stoma, but no ulcer could be seen. 25.1.49: barium meal showed posterior gastro-enterostomy with excessive resting juice. No ulcer could be seen. 31.1.49: fractional test meal showed no excess of acid. In Feb 1949 an exploratory laparotomy was carried out. The gastro-enterostomy appeared to be quite satisfactory and so gastrotomy was carried out but still no ulcer could be found. He made an uneventful recovery and was discharged free from pain. In June 1949 he was readmitted having had a haematemesis of about 1 pint. His Hb on admission was 70%. Gastroscopy was again carried out but failed to show an ulcer. After his discharge he continued to have intermittent attacks of epigastric pain but managed to continue his work until April 1950 when he had yet another haematemesis of about 1 cupful. This was followed by melaena. He was readmitted on 27.4.50. On examination - pale, ill-looking man complaining of abdominal pain. BP 110/60. p 60. Abdomen - epigastric distension. Marked tenderness just to the right of the midline. Hb 62%. A ryles tube was passed and 20oz of dark coloured material was aspirated. 28.4.50 - collapsed while on a bed-pan - pulse became rapid and imperceptible. Plasma drip was started and another doctor was asked to see him with a view to operation. During the day he was given 1 pint plasma, 2 pints blood and 1 pint glucose saline, and by 7pm his BP was 120/65. Operation 28.4.50. The abdomen was opened by a long right paramedian incision. Many coils of intestine were found adherent to the old scar. Also many adhesions round the site of the gastro-enterostomy. Partial gastrectomy was carried out with removal of the gastro-enterostomy stoma and about 4" of jejunum. An end-to-end anastomosis of jejunum to stomach was performed. At the end of the operation the patient’s condition was satisfactory and he made a good progress until 10.5.50. He then suddenly complained of cramp like abdominal pain and vomiting. His abdomen became distended and on 11.5.50 it was obvious he had an intestinal obstruction. Operation 11.5.50. The abdomen was opened through a long left upper paramedian incision. There were many loops of distended small bowel. Firmly attached to the anterior abdominal wall about 2" to the left of the umbilicus was a fat, swollen band of omentum and adherent to the right hand edge of this band was a loop of small bowel. Passing behind the omental band and between the adherent loop of small bowel was another loop of small bowel which had been obstructed. The offending piece of omentum was removed and the obstruction relieved. After this the patient made an uninterrupted recovery.

PATHOLOGY

The specimen consists of the anterior half of the resected stomach viewed from behind. At the lower end of the specimen the gastro-jejunostomy can be seen. At one end, the jejunal loop can be seen at the bottom right and corner. The other end of the loop has had part of its wall cut away to expose a shallow peptic ulcer with flecks of lack, altered blood outlining it. A small piece has been taken for histology. there appears to have been a good deal of fibrous contraction and the orifice between stomach and the right hand end of the intestine is small and can only be seen through the side of the jar.