Paper Title (Use Style: Paper Title) s1

Thermography in abdominal comorbidity in gastric carcinoma: case report

Marko Banić 1*, Darko Kolarić 2, Tonći Božin 1, Tomislav Kuliš 3, Mirjana Vukelić 1, Željko Herceg 4, Lidija Petričušić 1, Svetlana Antonini 5 1 University Hospital Dubrava, Division of Gastroenterology, Zagreb, Croatia 2 Ruđer Bošković Institute, Centre for Informatics and Computing, Zagreb, Croatia 3 University Hospital Rebro, Department of Urology, Zagreb, Croatia 4 Universitiy Hospital Sestre Milosrdnice, Division of Radiology, Zagreb, Croatia 5 Primary Health Care Zagreb - Center, Department of Radiology, Zagreb, Croatia * [email protected]

Abstract – There is a need for simple, noninvasive and malignant neoplasms in mammals [6]. Diets rich in salted, reproducible test that could accurately reflect the inflammatory smoked or pickled foods and the consumption of nitrites and activity, and could be used safely and repeatedly in detecting nitrates may increase cancer risk [7]. gastrointestinal symptomatology, such as diverticulitis. The aim of this study was to present the possibility of thermal imaging in assessing the inflammatory activity of diverticulitis as a comorbid finding in gastric carcinoma. The authors present the case of male patient with newly diagnosed gastric carcinoma and diverticulitis. The MSCT showed diverticula but no inflammation witch was observed on the thermal image and confirmed on colonoscopy. This case report pointed out to diagnostic potential of infrared thermographs as a feasible and noninvasive method in evaluation of comorbidities in malignant disease, such as gastric carcinoma.

Keywords – gastric carcinoma; diverticulitis; comorbidities; Figure 1. Gastric carcinogenesis MSCT; thermography Diets lacking fresh fruit and vegetables as well as vitamins C I. INTRODUCTION and A may also contribute. Smoking is also associated with an Carcinoma of stomach is the leading cause of cancer related increased incidence of gastric cancer [8]. Pernicious anaemia death in the last century worldwide but there are marked carries a small increased risk for gastric carcinoma, as well as geographical variations in incidence [1]. It is extremely after partial gastrectomy [9]. No predominant genetic common in China, Japan and parts of South America abnormality has been identified, although cancer risk is (mortality rate 30-40 per 100 000), less common in the UK increased in first-degree relatives of patients. Virtually all (12-13 deaths per 100 000) and uncommon in the USA [2]. tumours are adenocarcinomas. Cancers are either “intestinal”, Studies of Japanese migrants to the USA have revealed a arising from areas of intestinal metaplasia, or “diffuse”, much lower incidence in second-generation migrants, arising from normal gastric mucosa. Intestinal carcinomas are confirming the importance of environmental factors [3]. more common. Diffuse cancers occur in younger patients. Gastric carcinoma is more common in men and the incidence Early gastric cancer is usually asymptomatic but may rises sharply after 50 years of age. The overall prognosis is occasionally be discovered during endoscopy. Two-thirds of poor, with less than 30% surviving 5 years, and the best hope patients with advanced cancer have weight loss and 50% have for improved survival lies in greater detection of tumours at an ulcer-like pain. Anaemia from occult bleeding is also earlier stage. It is important to know that 20% of all common. Metastases occur most common in the liver, lungs, carcinomas occur in the gastrointestinal tract, and gastric peritoneum and bone marrow. Standard diagnostic workup carcinoma is the second most common among them, after includes physical exam, laboratory testing, endoscopic colon cancer. There is a strong link between H. pylori visualization, and for disease staging we use endoscopic UZV infection and gastric cancer. H.pylori infection results in and imaging methods such as MSCT of the thorax and chronic gastritis witch eventually leads to atrophic gastritis abdomen. PET-CT should also be performed in disease and intestinal metaplasia – a premalignant pathological staging. Identification of polyp on CT is size dependent, with change, as shown in Figure 1 [4]. Acquisition of infection at large lesions (≥10mm) accurately detected and small lesions an early age may be important [5]. The cytotoxin-associated (6-9mm) identified with moderate to good sensitivity [10]. gene A (CagA) protein of H. pylori, which is delivered into Resection offers the only hope of cure [11]. In patients with gastric epithelial cells, is an oncoprotein that can induce inoperable tumours, palliation of symptoms can sometimes be

1 achieved with chemotherapy using FAM (5-fluorouracil, water and electrolytes intake. Perforations with peritonitis doxorubicin and mitomycin C) or ECF (epirubicin, cisplatin and/or abscess formation, as well as persistent intestinal and fluorouracil). Various endoscopic procedures are in use obstruction and persistent bleeding represent clear indications for symptom relief. In our case the patient has gastric cancer for surgery. and diverticulitis as comorbidity. Diverticula of the colon are, The aim of this study was to present the possibility of thermal in most cases, acquired out-pouching of the mucosal layer of imaging in gastric cancer comorbidities. the bowel through gaps in the bowel wall musculature. Unlike congenital diverticula, their walls are not formed from all layers found in normal bowel. Their prevalence correlates II. METHODS significantly with advancing age [12]. With advancing age, In this case report, for the purpose to evaluate the extent of there is increase in both the number and size of diverticula. gastric carcinoma and presence of diverticulitis the male Men and women are about equally affected. About 80-95% of patient underwent the standard diagnostic workup that diverticula develop in the sigmoid colon. The aetiology of included physical exam, laboratory tests, EGD and total diverticular disease is not completely understood. A crucial colonoscopy with terminal iloescopy and pathohistologial factor in the pathogenesis of diverticula is an increase in analysis as well. The MSCT imaging of the abdomen and intraluminal pressure in the bowel and intensified intestinal thorax was performed in order to stage the malignant disease. motor activity. Decisive co-factors in the development of The patient also underwent the thermal imaging, provided in diverticula include changes in life-style and nutrition, in real time using infrared camera Thermo Tracer TH7102WL particular the increased consumption of foods low in dietary (NEC, Japan). The imaging itself was preformed accordingly; fibres [12]. Over 80% of persons with diverticula remain patient was positioned in front of the camera, approximately at asymptomatic indefinitely. Inpatients with so-called 1m so that the whole abdomen was captured by the camera “symptomatic” diverticulosis, complaints are often not due to lens. He was undressed and asked to stand in front of the the diverticula themselves but most often result from a co- camera not touching his abdomen in order to achieve thermal existing irritable bowel syndrome [13]. Asymptomatic equilibrium. This process took about 5 to 10 minutes and was diverticulosis can progress to diverticular disease when documented as a thermogram. Upon achieving equilibrium the complications occur. Complications of diverticulosis include patient´s abdomen was cooled with alcohol and then interval diverticulitis, diverticular bleeding, covered or free thermograms were taken until equilibrium was achieved again. perforation, diverticular stenosis and the formation of fistulae. Differences in thermal patterns and peak temperatures were The most common complication is diverticulitis. One documented. The measurements were done before the consequence of stool retention may be the formation of preparations for endoscopy, to exclude the potential influence fecoliths within the diverticular pouch, leading to bacterial of bowel cleansing and endoscopic procedure itself, as well. inflammation of the diverticulum and pressure ulcerations. The thermographic imaging itself was performed after the Consequences include perforation with abscess formation, MSCT scanning and prior to colonoscopy. peritonitis and fistulation. The clinical signs of acute diverticulitis include colicky abdominal pain, fever and alterations in laboratory parameters. There may also be III. CASE REPORT diarrhoea or constipation, reduced general health, loss of We present the case of a 43-year old with newly diagnosed appetite and sometimes vomiting. The physical examination of gastric adenocarcinoma. The patient presented to the patients with diverticulitis reveals a bloated abdomen painful emergency room with severe abdominal pain. Before to pressure. As the patient progresses through the stages of admittance to Clinical Hospital Dubrava an peridiverticulitis and pericolitis, the spreading peritonitis leads esophagogastroduodenoscopy was performed witch showed to development of the clinical picture of acute abdomen. carcinoma on the back wall of the gastric corpus. The Solitary or multiple diverticula, especially in older patients, patohistological analysis confirmed the diagnosis of are a common coincidental findings of radiological (barium adenocarcinoma. After admittance the preoperative workup enema) or endoscopic (colonoscopy) examinations obtained included laboratory testing and imaging methods for staging primarily for some other indication. More recently, however, the carcinoma. Laboratory testing showed no abnormalities ultrasound has enjoyed increasing application in the diagnosis but the preformed MSCT showed thickening of the gastric of diverticulitis. Limiting factors for the sonographic detection small curve 4 cm in diameter and a couple of affected of diverticula include significant obesity in the patient, distal perigastric lymph nodes, as shown on Figure 2. Alongside the diverticula and very small diverticula. Computed tomography findings in the stomach the MSCT also showed nonspecific (CT) is capable of providing data not only on the presence or opacification of the colon wall that could indicate an absence of diverticula but also in regard to inflammatory inflammatory process (Figure 3). Beside the diverticula there thickening of the bowel wall and infiltration of the were no radiological sings of diverticulitis. Encouraged by this perisigmoid and pericolic adipose tissue. Abscesses, because finding the authors performed thermal imaging of the patient’s they are collections of fluid, are also reliably identified. Mild abdomen. The thermal image showed signs of inflammation in to moderate cases of diverticulitis are treated conservatively spots that could reflect the position of the diverticula shown with intravenous antibiotics, parenteral nutrition and adequate on the MSCT, as shown on Figure 4. To confirm the diagnosis

2 of diverticulitis a colonoscopy was performed and IV. DISSCUSION diverticulitis was verified. 5 days later the patient was In evaluating gastric carcinoma the standard workup operated. The procedure went fine. includes physical exam, laboratory work, esophagogastroduodenoscopy and imaging methods such as MSCT for staging and evaluation of associated disease. Taking into account the standard imaging procedures for evaluating the activity and extent of inflammatory disease, the thermal imaging, also known as clinical thermography, is capable of providing non-contact, in vivo diagnostic information in regard to body temperature. Infrared imaging also has the possibility to map small variations of the body surface temperature and identify thermal abnormalities that accompany various physiological conditions. Being a passive technique, (i.e. without external sources of radiation) thermography is noninvasive and therefore intrinsically harmless. The findings in this case report indicate that thermography was superior to Figure 2. MSCT showing gastric carcinoma prior operation radiological imaging techniques in detecting inflammatory conditions such as diverticulitis in a setting of gastric carcinoma. The MSCT showed diverticula but no clear signs of inflammation opposed to thermography. We believe that blood vessel activity during the process of active inflammation induces the increase in body surface temperature that would be higher than in normal tissue [14]. Our findings point out to diagnostic potential of infrared thermography as a feasible and noninvasive method in evaluation of disease activity, in the patient with inflammatory abdominal comorbidities, such as diverticulitis [15-16]. There is a need for further basic and clinical studies, in order to evaluate and validate the method of thermal imaging by the means of infrared thermography in assessing the activity and extent of intestinal inflammation, and Figure 3. MSCT prior operation showing colon diverticula and opacification other intraabdominal inflammatory conditions, as well. of the colon wall

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