A 69-year-old male patient was admitted to the Department of Haematology because of fatigue and dizziness lasting 1 month. The patient had fatigue for 1 month, and the symptom was gradually aggravated 1 week prior to his visit.The patient was unable to carry out physical activity and had dizziness. Five years ago, the patient was hospitalised at the Department of Haematology of our hospital for treatment of thrombocytopenia and diagnosed with ITP with a platelet count of 7×109/L on admission. After treatment with 30mg qd of prednisone for 3 days, the patient was voluntarily discharged from the hospital. The patient took platelet-elevating drugs irregularly after discharge and did not return to re-examination. No family history of cancer or haematological diseases. On admission, the patient’s temperature was 36.6°C, heart rate was 77 bpm, respiratory rate was 16 breaths per minute, blood pressure was 138/97 mmHg, and the physical examination revealed no positive sign. But the patient’s routine blood test showed a haemoglobin level of 63 g/L, platelet count of 34×109/L, bone marrow smear indicated hypochromic microcytic anaemia, enhanced abdominal CT examination revealed stage T1−2N0 cancer (Fig. 1), gastroscopy revealed 1.5×1cm2 necrotic foci at the posteriorwallof the lessercurvatureof the gastricbody, and apathological test confirmed adenocarcinoma (Fig. 2). The patient was finally diagnosed with gastric cancer.
The patient was transferred from the Department of Haematology to the Department of General Surgery and double-checked routine blood examination (haemoglobin level, 71g/L; platelet count, 36×109/L). After amultidisciplinary discussion,we decided to continuously subcutaneous inject 15000 IU of thrombopoietin (TPO) into the patient for 2 weeks. However, no satisfactory therapeutic effect was found after re-examination. Accordingly,on the sixth day,we combined intravenous immunoglobulin (IVIG; 400mg/kg) for 5 days. Last, laparoscopic total gastrectomy with D2 lymphadenectomy (LTG-D2) + splenectomy + Braun's anastomosis was performed after platelet transfusion. Serious abdominal adhesion was observed during the operation, and the operation time lasted 7 hours. On the first day after operation, the patient was re-examined with routine blood test and revealed a haemoglobin level of 80 g/L and platelet count of 62×109/L. On the fifth day after operation, 200–400mL of a dark red blood-like fluid was founded from the patient’s nasogastric tube. We considered gastrointestinal anastomotic stoma bleeding and decieded to use somatostatin, a proton pump inhibitor, thrombin and suspended red blood cells for treatment. Bleeding of the anastomotic stomagradually decreased, but dark-brown urine was noted on the 13th day after operation. The patient was re-examined with routine blood test and revealed a white blood cell (WBC) count, haemoglobin level, and platelet count of 21.93×109/L, 52g/L and 116×109/L, respectively. The patient’s liver function was generally normal. Routine urine test showed 4 + bilinogen and 11.9% reticulocytes. Indirect and indirect anti-human-globulin (Coomb’s test) tests were negative. After remote consultation in the Department of Haematology of the West China Hospital of Sichuan University, blood transfusion-related haemolysis was excluded, considering possibilities of Coomb's test-negative autoimmune haemolysis, infection, tumour and other factors. We considered the effects of hormones and immunosuppressants on the anastomotic stoma and infection control, decided to temporary observation and adjust cefoperazone/sulbactam to imipenem/cisastatin (1g q8h).Thereafter, the patients was regularly examined through routine blood and urine tests, and the relevant indices gradually improved. The patient was discharged on the 26th day after operation with a WBC of 8.56×109/L, haemoglobin level of 62g/L and platelet count of 57×109/L (Fig. 3).
The patient’s postoperative pathological test: stomach and lymph nodes: moderately and highly differentiated tubular adeno carcinoma invading the muscularis mucosa without lymph node metastasis (Fig. 4); spleen: congestive splenomegaly (Fig. 4). Pathological stage: T1aN0M0, stage IA. The patient was followed up 3 months and 6 months after operation and re-examined with routine blood test. A WBC count, haemoglobin level and platelet count of 5.72/ 6.35×109/L,92/114g/L and 44/41×109/L, respectively.