Missed Diagnosis of Stomach Cancer

This case involves a fifty-seven-year-old male, with no significant medical history. He was referred from his primary care provider to the emergency department for evaluation of severe headaches, fever, chills, abdominal pain, and significant weight loss. A year earlier, when he started developing nonspecific abdominal pain, he was in normal health but started to shed weight quickly without intention. The patient was simply worked up for gastritis in the ER and discharged with a PPI prescription for esophageal reflux disease. Approximately six months later, the patient returned to the ER with similar complaints, but with increased pain. A CT and MRI of the abdomen demonstrated several masses with findings compatible with metastatic disease. An endoscopy with biopsy revealed a large, mucosal mass and pathologic examination of the gastrointestinal biopsy sample revealed a poorly differentiated gastric adenocarcinoma.

Question(s) For Expert Witness

1. What is the best modality for early diagnosis that is both sensitive and specific to this type of disease?

Expert Witness Response

Esophagogastroduodenoscopy has a diagnostic accuracy of 95%. This relatively safe and simple procedure provides a permanent color photographic record of the lesion. This procedure is also the primary method for obtaining a tissue diagnosis of suspected lesions. Generally a biopsy of any ulcerated lesion should include at least 6 specimens taken from around the lesion because of variable malignant transformation. In selected cases, endoscopic ultrasound may be helpful in assessing depth of penetration of the tumor or involvement of adjacent structures. Additionally, a double-contrast upper GI series and barium swallows may be helpful in delineating the extent of disease when obstructive symptoms are present or when bulky proximal tumors prevent passage of an endoscope to examine the stomach distal to an obstruction. These studies are only 75% accurate and should for the most part be used only when upper GI endoscopy is not feasible.