Administração de nutrição enteral em posição prona, volume de resíduo gástrico e outros desfechos clínicos em pacientes críticos: uma revisão sistemática / Administration of enteral nutrition in the prone position, gastric residual volume and other clinical outcomes in critically ill patients: a systematic review

RESUMO Esta revisão sistemática de estudos longitudinais objetivou avaliar o efeito da administração da dieta enteral em pacientes críticos adultos e pediátricos em posição prona no volume residual gástrico e em outros desfechos clínicos. A busca da literatura foi conduzida nas bases de dados PubMed®, Scopus e Embase, a partir de termos relacionados à população e à intervenção. Dois revisores independentes analisaram os títulos e resumos, e a coleta dos dados foi realizada a partir de uma ficha padronizada. Discrepâncias foram resolvidas por um terceiro revisor. A qualidade metodológica dos estudos foi avaliada considerando o potencial para erros sistemáticos e os dados analisados qualitativamente. Quatro estudos com pacientes adultos e um com pacientes pré-termos foram incluídos. O volume residual gástrico foi avaliado como principal desfecho: três não diferiram no volume residual gástrico entre as posições prona e supina (p > 0,05), enquanto um estudo demonstrou maior volume residual gástrico durante a administração da dieta em posição prona (27,6mL versus 10,6mL; p < 0,05), e outro apresentou maior volume residual gástrico na posição supina (redução do volume residual gástrico de 23,3% na posição supina versus 43,9% na posição prona; p < 0,01). Dois estudos avaliaram a frequência de vômitos, sendo maior na posição prona em um estudo (30 versus 26 episódios; p < 0,001) e sem diferença significativa em outro (p > 0,05). Incidência de pneumonia aspirativa e de óbito foram avaliadas por um estudo, não sendo observada diferença entre os grupos (p > 0,05). A literatura acerca da administração de dieta enteral em pacientes críticos em posição prona é escassa e de qualidade limitada, e os resultados sobre volume residual gástrico são contraditórios. Estudos observacionais com tamanho amostral apropriado deveriam ser conduzidos para fundamentar conclusões sobre o tema.

ABSTRACT This systematic review of longitudinal studies aimed to evaluate the effect of enteral feeding of critically ill adult and pediatric patients in the prone position on gastric residual volume and other clinical outcomes. A literature search was conducted in the databases PubMed, Scopus and Embase using terms related to population and intervention. Two independent reviewers analyzed the titles and abstracts, and data collection was performed using a standardized form. Discrepancies were resolved by a third reviewer. The methodological quality of the studies was evaluated considering the potential for systematic errors, and the data were qualitatively analyzed. Four studies with adult patients and one with preterm patients were included. The gastric residual volume was evaluated as the main outcome: three studies did not show differences in the gastric residual volume between the prone and supine positions (p > 0.05), while one study showed a higher gastric residual volume during enteral feeding in the prone position (27.6mL versus 10.6mL; p < 0.05), and another group observed a greater gastric residual volume in the supine position (reduction of the gastric residual volume by 23.3% in the supine position versus 43.9% in the prone position; p < 0.01). Two studies evaluated the frequency of vomiting; one study found that it was higher in the prone position (30 versus 26 episodes; p < 0.001), while the other study found no significant difference (p > 0.05). The incidence of aspiration pneumonia and death were evaluated in one study, with no difference between groups (p > 0.05). The literature on the administration of enteral feeding in the prone position in critically ill patients is sparse and of limited quality, and the results regarding gastric residual volume are contradictory. Observational studies with appropriate sample sizes should be conducted to support conclusions on the subject.

Modificaciones estructurales en el estómago y el hígado de Paralabrax maculatofasciatus (Steindacher, 1868) ante situaciones de estrés crónico / Structural modifications in the stomach and liver of Paralabrax maculatofasciatus (Steindacher, 1868) under chronic stress conditions

Para determinar el efecto del estrés a nivel del aparato digestivo, organismos de la especie Paralabrax maculatofasciatus fueron sometidos a dos modelos de estrés: el primero por descenso en el nivel del agua (n=84) por 30 y 60 minutos diariamente, y el segundo por cultivo a altas densidades (n=96) de 1,6 y 3,2 kg/100 1. Se tomaron muestras de estómago e hígado y se fijaron en formol al 10%. Los tejidos fueron incluidos en parafina, realizándose cortes de 6 um que se tiñeron con H-E. En ambas condiciones de estrés el estómago presentó cambios morfológicos importantes tales como hipertrofia y atrofia en la capa mucosa. En el hígado se observaron cambios de coloración y textura, así como hemolisis, inflamación y necrosis. Por descenso en el nivel del agua el estómago presentó diferencias morfométricas significativas (P<0,05), entre los diferentes tiempos de exposición al estrés y/o entre los días de muestreo en algunos de los parámetros medidos. Por cultivo a altas densidades, se observaron diferencias significativas en algunos parámetros, 4 de ellos presentaron interacción densidad-muestreo y el resto presentaron diferencias significativas sin interacción. El hígado presentó diferencias significativas (P<0,05) en el perímetro nuclear entre los diferentes días de muestreo. El estrés provocado por alta densidad de cultivo resultó ser el factor que provocó daños tisulares más severos en los órganos estudiados, de ahí la importancia de mantener las condiciones adecuadas en los cultivos, como son el nivel de agua y el número de organismos por estanque.

To determine stress effects at histological level in the digestive system, organisms of Paralabrax maculatofasciatus were submitted to 2 stress models. One of decreasing the water level (n=84) for 30 and 60 min daily, and another at high density cultures (n=96) of 1.6 and 3.2 Kg/1001. Stomach and the liver samples were fixed in 10% formalin, embedded in paraffin wax, sectioned at 6 urn and stained with haematoxylin-eosin. In both stress conditions, the stomach showed important morphological changes in the mucosa layer, such as hypertrophy and atrophy. In the liver, coloration and texture changes were observed as well as haemolisis, inflammation and necrosis. In the water decrease model, the mucosa layer of stomach showed significant morphometric differences (P<0.05), between different times of stress exposure and/or between different days, in some of the measured parameters. In the high-density model, significant differences in the stomach mucosa showed a sampling-density interaction in 4 parameters and 6 other parameters showed differences with no interaction. Liver showed significant differences in nuclear perimeter between sampling-days. Stress caused by high-density culture proved to be the factor that caused the most serious tissue damage.

Gastric volvulus - A review of 38 cases / Volvo gástrico: revisão de 38 casos

BACKGROUND: Gastric volvulus is frequently an asymptomatic disease, and it is usually diagnosed during radiographic examination of the superior digestive tract. The acute form, however, can spawn serious and lethal clinical consequences. This disease is defined by the anomalous rotation of the stomach over itself, and it can be classified according to type, extension, direction, etiology, and clinical presentation. AIM: To review the records from 38 patients with gastric volvulus diagnosed in the Hospital das Clínicas of University of São Paulo between 1968 and 2001. METHODS: This is retrospective analysis of 38 patient records. It was collected from each patient: name, age of first symptom appearance, gender, main clinical findings and complementary exams, volvulus type, extension, direction, etiology, and clinical presentation, therapeutic procedures, type of surgery performed, eventual recurrence, and long-term evolution. RESULTS: It was observed that occurrences of gastric volvulus are mainly secondary (75.8%). For the majority of patients (n=33), surgery was chosen as the treatment option: chronic disease in 29 cases and acute in four. Conservative treatment was reserved only for patients with no clinical conditions to surgical treatment. Anterior gastropexy was associated to high recurrence rates. Suturing the low gastric curve to the hepatic capsule and the transverse colon to the left subphrenic space (Tanner´s operation) seemed to be the technical treatment of choice for primary gastric volvulus. CONCLUSION: Treatment of gastric volvolus must be tailored according the etiology of the disease.

RACIONAL: O volvo gástrico é frequentemente condição assintomática e diagnosticado em exame radiológico feito por outras causas. A forma aguda, no entanto, pode ter consequências graves e letais. Ele é definido como rotação anômala do estômago nele próprio e classificado de acordo com o tipo, extensão, direção, causa e apresentação clínica. OBJETIVO: Apresentar aspectos clínicos e morfológicos de volvos gástricos. em 38 pacientes. MÉTODOS: Análise retrospectiva onde foram coletadas informações registradas sobre 38 pacientes a cerda da idade, surgimento do primeiro sintoma, gênero, principais achados clínicos, de exames complementares, tipo do volvo, causa, procedimentos terapêuticos, recidivas e evolução tardia. RESULTADOS: Em 75,8% o volvo foi secundário Na maioria dos pacientes a opção de tratamento foi cirúrgica. Ele era crônico em 29 e agudo em quatro pacientes. O tratamento conservador foi indicado somente aos sem condições clínicas para operações. Gastropexia anterior foi associada à alta taxa de recidiva. A sutura da pequena curvatura gástrica à cápsula hepática e cólon transverso na fossa subfrência esquerda (operação de Tanner) parece ser o tratamento de escolha nos volvos primários. CONCLUSÃO: O tratamento do volvo gástrico deve ser feito sob medida caso a caso e de acordo com a causa da doença.

Stress modulating antioxidant effect of Nardostachys jatamansi.

The rhizomes of Nardostachysjatamansi, the plant commonly known as Jatamansi have been described in Ayurveda for their soothing and sedative action on the central nervous system. In the present study, the anti-stress effect of hydroethanolic extract (70%) of N. jatamansi (NJE) was evaluated in reference to its antioxidant property. Wistar rats were divided into four groups: naive, stressed, and T-200 and T-500 stressed with oral pre-treatment of NJE 200 and 500 mg/kg, respectively. Restraint of rats in metallic chambers for 4 h at 4 degreesC was followed by sacrifice and assessment of stress-induced alterations in biochemical parameters, incidence and severity of ulcers. Lipid peroxidation (LPO) and NO levels in stomach and LPO, NO levels and catalase activity in brain, plasma corticosterone level and adrenal ascorbic acid were measured. In vitro antioxidant activity of NJE was studied by measuring the free radical scavenging activity. NJE showed potent antioxidant activity and significantly reversed the stress-induced elevation of LPO and NO levels and decrease in catalase activity in the brain. It inhibited the incidence of gastric ulcerations and reversed the alterations in biochemical parameters/markers of stress-induced gastric ulceration. NJE also significantly altered stress-induced increase in adrenal and spleen weights and decrease in level of ascorbic acid in adrenal gland. Elevation of plasma corticosterone level was negated dose- dependently. The findings suggest that the NJE possesses significant anti-stress activity, which may be due to its antioxidant activity.

O papel da enteroscopia de duplo-balão na síndrome de Peutz-Jeghers: relato de caso / The role of double balloon enteroscopy in the Peutz-jeghers syndrome: a case report

A síndrome de Peutz-jeghers é uma doença autossômica dominante caracterizada por polipose gastrointestinal (hamartomas), pigmentação mucocutânea e risco aumentado de neoplasias gastrointestinais (adenocarcinoma do cólon, duodeno, jejuno e íleo) e extra-intestinais (neoplasias do pâncreas, vias biliares, mama, ovário, testículo e últero). As principais complicações da síndrome são hemorragia digestiva e obstrução intestinal. O presente estudo enfoca o uso da enteroscopia de duplo-balão em um paciente com síndrome de Peutz-jeghers previamente diagnosticada, apresentadndo quadro de suboclusão intestinal internitente

Carcinoma adenoescamoso primário de estômago: relato de caso / Primary adenosquamous carcinoma of the stomach: a case report

O carcinoma adenoescamoso primário do estômago é um tumor raro, cuja incidência não excede 1 por cento dos tumores gástricos. Esse tumor mostra dois tipos celulares distintos: um escamoso e outro adenocarcinomatoso. É discutido um caso de um tumor raro e interessante do estômago, com relação à sua patogênese, diagnóstico e aspectos clínico-patológicos. Material e método: Reporta-se um caso de carcinoma adenoescamoso primário do estômago em uma paciente de cor branca de 51 anos, cuja patologia, exame endoscópico e histopatológico mostram a presença dos dois tipos celulares: adenocarcinomatoso e escamoso

Carcinoma de pequenas células do estômago: relato de caso / Small cell carcinoma of the stomach: case report

O carcinoma indiferenciado de pequenas células é uma neoplasia rara no estômago, morfologicamente análoga ao carcinoma avenocelular do pulmão. Caracteriza-se por apresentar curso clínico muito agressivo e aspecto macroscópico indistinguível do adenocarcinoma gástrico. Os autores apresentam um caso adicional ocorrido em uma mulher de 64 anos de idade. Foram revisados os principais aspectos clínico-paatológicos, imunosisstoquímicos e levamtadas algumas considerações sobre sua histogênese. A maioria dos achados foi semelhante àqueles descritos na literatura

Noninvasive Measurement of Gastric Accommodation by SPECT

No abstract available.

Rapunzel syndrome with a long tail.

A rare form of gastric trichobezoar extending into small bowel with varying gastrointestinal symptoms is known as Rapunzel syndrome. A case history of 6 years old boy is described. This is the twelfth patient with Rapunzel syndrome in the literature.

Effect of esophageal and gastric distention on bronchial hyper-responsiveness in patients with bronchial asthma.

OBJECTIVE: Over-eating is said to aggravate asthma though the mechanism is still unclear. We tried to study the mechanism by causing distention in oesophagus and stomach. METHODS: Fifteen patients with nocturnal asthma were studied in a random cross-over design. The esophagus and stomach of the subjects were distended with a balloon. The effect of the distention on the airways was measured by taking forced expiratory volume one second (FEV1), forced vital capacity (FVC) and bronchial hyper-responsiveness (BHR). RESULTS: Distention of stomach caused significant reduction in FEV1 on FEV1/FVC ratio but similar distention of esophagus did not. Histamine PD20 was decreased by 0.43 (SEM 0.28) doubling dose with gastric distention. However, with oesophageal distention no significant change was observed in PD20. CONCLUSION: It can be concluded that gastric distention leads to broncho-constriction as measured by FEV1, FEV1/FVC ratio along with increase in BHR probably by inducing airway inflammation. Therefore asthmatic patients should be advised to avoid large meals.

Gastrocolonic electrical response of the colon in patients with hepatosplenic mansonic schistosomiasis

Em humanos, imediatamente apos a primeira refeicao do dia, ocorre, frequentemente, uma necessidade premente de defecacao. Essa necessidade tem sido denominada de resposta gastrocolica. O ato de alimentar-se aumenta a motilidade colonica, porem, os padroes eletromiograficos dessas modificacoes ainda nao estao bem estabelecidos. O objetivo deste estudo e identificar as modificacoes eletromiograficas colonicas durante a resposta gastrocolica do colon esquerdo em uma populacao de pacientes portadores de esquistossomose hepatoesplenica. Eletrodos recobertos de teflon foram implantados ao...

Cirugía resectiva gástrica: complicaciones y secuelas / Gastric resective surgery: complications and sequelaes

Se revisa la fisiopatología del estómago operado así como las secuelas postoperatorias, destacando entre las precoces el Síndrome de dumping y los síndromes de asa y entre las alejadas, por una parte las hiperclorhidrias residuales y las úlceras anastomóticas y por otra, los defectos de absorción de causas digestivas preparietales; las anemias hipocromas sideropénicas y las macrocíticas

Alteraciones de la mecanosensibilidad gastrica, del vaciamiento gastrico y de la electrograstrografia en pacientes con dispepsia no organica (DNO) / Abnormalities in gastric mechano sensitivity, gastric emptying and electrogastrography in non organic dyspepsia (NOD)

The aim to study the alterations in mechanosensitivity gastric emptying, and electrogastrography (E.G.G.) in a population of patients suffering from N.O.D. eighteen controls (9 males, 9 females, mean age 49.33 years old0.01). Twenty porcent of controls showed isolated tachygastria, but dominant frecuencies never were higher than 6 c.p.m and never last more than 8 percent of the total recording time. Sixty eight point seventy five porcent of N.O.D. showed arrhytmias, 48 percent of tachygastrias were in the range 30-60 percent of total recording time. No differences in gastric emptying between patient presenting pain with=<700ml. and <700ml. of balloon inflation were seen. Patients with sensorial treshold=<700ml. showeed less frequent tachigastria (0.01

Gastroenterological manifestations of sickle cell disease

Sickle cell hemoglobinopathy is a common genetic disorder which is prevalent in certain areas of the Kingdom of Saudi Arabia. it is characterized by repeated hemolytic and vasoocclusive crises which lead to widespread vascular occlusion and subsequent multiple organ infarctions, Affected individuals present with a wide variety of gastrointestinal disorders mimicking vasoocclusive episodes causing diagnostic confusion and delays that may catch the unwary clinician. This article briefly reviews the gastroenterological manifestations of sickle cell disease

Comparación de la mecanosensibilidad gástrica en pacientes con dispepsia funcional (D.F.) / Comparison between gastric and esophageal mechano-sensitivity in patients with functional dyspepsia

Patients with non ulcer dyspepsia (NUD) and lowered mechano sensitivity tresholds in stomach may have lowered mechano sensitivity treholds in oesophagus also. The aim was to check this hypothesis. Methods: 39 patients with NUD (11 men and 24 women, mean age 57 years, SEM 3.72, range 17-86) and 20 controls (10 men, 10 women, mean age 49.3 years, SEM 3.72, range (31-66) were studied. Organis diseases were discarded. Gastric mechano sensitivity was studied with a latex ballon of low compliance, 8 cm lenght, conected to a manometer. Ballon was inflated "in ramp"at 10 ml/sec. and "first sensation", disconfort", and "pain" were registered. At 900 ml inflation was stopped if pain was not evoked. Oesophageal mechano sensitivity was studied with another latex ballon of low compliance which, after inflated with 15 ml. of air, was 3.5 cm. in diameter. Esophageal ballon was inflated "in ramp" (1 ml/sec) up 15 ml. and deflated in 2 cm step from 36 to 22 cm from SDA. Infaltion was stopped whrn symptoms (pain or disconfort were evoked. Oesophageal acid perfusion test was performed. Results: 83.4 per cent of controls completed up 700 ml. of gastric distension vs. 35.9 per cent of patients with NUD (p>0.001). No significatives differences in intra-ballon pressure slope were observed between both groups. 79.2 per cent of NUD patients had chest pain with oesophageal ballon distension =<7 ml. vs. 5 per cent in controls (p>0.001). Mean volumes were 7.03 ml. (NUD) and 11.9 per cent (controls) (p=0.001). 63 per cent of dyspeptic patients with lowered gastric sensitivity tresholds (< 700 ml) had oesophagic symptoms with inflation volumes =< 7 ml. There was a positive correlation is stomach and oesophageal mechano sensiticities variations (r= 0.75 +/-0.58, p>0.01). Whem analyzed with that results, oesophageal acid perfusion test showed 38.5 per cent of "mixed sensitivities" (both mechano-and chemo-), 30.7 per cent of "mechano sensorials" (negative acid test, positive ballon test), and 10.3 per cent of schemo sensorials" (positive acid test only). In 20.5 per cent both tests were normal at the moment they were done. These results agreed with our previous experiences in oesophagus. Conclusions: It was concluded that a significative proportion of NUD patients had lowered tresholds for mechano stimulation of stomach and oesophagus at the time that both tests were done. Such alterations support the hypothesis that a more general mechano-sensitivity alteration in present in patients with NUD.

Dispepsia no ulcerosa o dispepsia por disquinesia gastrica / Non-ulcer dyspepsia or gastric diskinesia dypepsia

La dispepsia no ulcerosa (D.N.U.) es una enfermedad funcional digestiva muy frecuente; es la responsable del 30-40 por ciento de los casos con enfermedad funcional; su patogénesis aun no est totalmente explicada, pero se observa una distensión g strica que es muy dolorosa y explica la sintomatología ulcerosa de los pacientes. De acuerdo con la experiencia clínica de tratamiento exitoso con drogas anti ulcerosas tipo H2 (no con alimentos) y drogas prokinéticas y a los recientes informes sobre la acción de las anti H2, que no sólo controla la acidez (que no tiene nada que ver con esta enfermedad) sino que ejerce una acción prokinética g strica, se sugiere que el mecanismo de la sintomatología clínica, es debida a distensión g strica dolorosa, y a su control kinético por los anti H2: por este motivo se propone el nombre de DISPEPSIA POR DISQUENESIA GASTRICA.

Gastric physiological and microbial changes in chronic renal failure patients under dialysis

Patients with chronic renal failure have been reported to have an increased incidence of gastric disease, 50 patients with renal failure [25 under haemo dialysis and 25 under peritoneal dialysis] and 12 controls, all suffering of gastritis were subjected to this study with the aim to characterise changes in the gastric physiology and microbial ecology, in end stage renal failure. Symptomatic gastritis was found in 45 of 50 uraemic patients as detected by endoscopic study. Gastric juice urea concentration, blood urea and serum creatinine are all significantly high in haemodialysis and peritoneal dialysis cases than controls. Also gastric juice pH is higher in cases than controls [3.7, 2.5, P<0.01 respectively]. In spite of more alkaline pH values, renal failure cases have high serum gastrin level detected by RAST method than controls [215.2, 185.1 compared to 136 pg/ml, P<0.05 respectively]. High gastric juice urea was expected to encourage urease-producing organisms especially H. pylori to colonise the stomach, yet culturing H. pylori from gastric aspirate and biopsy recovered it to nearly the same prevalence values from renal failure cases and controls [44%, 41.7%]. Serum Ig[G] anti H. pylori antibodies were also detected to nearly same incidence level in cases and controls [42 - 41.7%]. In spite of high urea level in all patients yet H. pylori was detected in only 46% of them. Now the prime mechanism in gastritis is not certain species of bacteria but it is the uraemic state that destruct the gastric mucosa and pump out hydrogen ions. This alkalinisation favours growth of many aerobes, anaerobes and candida species

Ulcera gastroduodenal, su ubicación en estómago y duodeno: revisión endoscópica / Gastroduodenal ulcer, its place in the, stomach and duodenum: an endoscopic study

Se analizaron los resultados de 568 exámenes endoscópicos del tubo digestivo alto realizados en un periodo de 52 meses determinandose los sitios preferenciales de los asentameintos de las úlceras gastroduodenales. El gran porcentaje de las úlceras gástricas, se localiza hacia la curvatura menor ya sea en el ángulo o el la mucosa antral; en las úlceras duodenales la localización preferencial es un bulbo duodenal hacia la pared posterior. Existe una predisposición del sexo masculino a contraer la enfermedad respecto del femenino con una relación de 2,09; 1 La aparición en grupos etáreos, difiere en ambos grupos de ulcerosos siendo la úlcera duodenal de aparición más temprana respecto a la úlcera gastrica.

Leiomyoblastoma of the stomach, case report

A 35 years old lady presented with anaemia and signs and symptoms of pyloric obstruction.Radiological and endoscopic investigations showed an ulcerating tumor. Laparatomy revealed an antral tumor. Bilroth [1] partial gastrectomy was performed. Histopathology revealed a leiomyoblastoma. A review of literature is also presented. A 35 years old lady was admitted to hospital on the 29th August, 1990, complaining of repeated vomiting of two weeks duration, preceded by two months history of epigastric pain and heaviness. She tolerated fluid diet, otherwise, she vomited ordinary meal. The epigastric pain was moderate in severity, constant, aggravated by meal and radiate to the back. She had also loss of appetite and loss of weight associated with generalized s Patient had no previous major relevant illness nor previous operation. She is married and has three children in good general health. No family history of gastric problem nor significant illness. On examination, she looked pale, emaciated, not jaundiced, not cyanosed, not dysponic, no lymphadenopathy and JVP was normal pulse: 80/mBl-pr 120/70, Temp: 37, 2 °C chest: scattered rhonchi with good air entry, Heart: normal double rhythm. Abdomen: soft, visible peristallic movement, tender epigastric mass which was firm, fixed, oval in shape with irregular margins, succession splash was positive. PR: revealed melena stool. Nervous system and extremitied were intact. Investigations on admission: Hb: 8.3 g/dl, pcv: 28.4%, R.B.C count: 3.76 106 W.B.C count 9.3 10 platelets: 241 10 E.S.R: 25 mm/hr. and a blood film shoewd hypochromic, microcytic with mild neutrophilia 76%, T.S.B: 0.4 mg/dl, SGPT: 8/dl, SCOT: 12/dl, serum alkaline phosphatase: 8 K.A/dl, Blood urea: 28 mg/dl, P.B.S 80 mg/dl, senun.Na 125 megjdl, serum.K: 3.6 meg./dl, Blood group: BRH+ve [for patients of crossed matched blood wee prepared]. Barium meal shows moderately enlarged stomach, filling defect in the prepyloric region, duodenal cap deforrnity. Endoscopy: everted showed no oesophagcal lesion, infiltrating growth in the antrum with everted edges and a centrally placed larg ulcerating lesion Biopsy was taken Histopathological study of endoscopic biopsy 'severe chronic gastritis with marked intestine metaplalsia, area of necrotic slough heavily infiltrated, but no evidence of malignancy". The patient was prepared for surgery operation was performed on the fifth day of admission after stabilization of the general condition of the patient laparatomy through an upper midline incision showed a firm fixed mass of 58 cm in the pyloric region of the stomach It has a smooth surface and adheres postenoly to the upper part of pancreatic head and neck. No lymph nodes were detected in the nearby area liver was free from metastasis. Bilroth 1 partial gastrectoimy was performed The resection involved the distal third of the stomach about 5 cm from the mass and whole pylorus and two centimeter of healthy first part of deodenum. Whole specimen was sent for histopatholgy. Gross: partial gastrectomy 14 10 cm. there is an alcerated tumor in the pyloric region m 66 cm which opened posterioly. Both ends of the resection are not invoiced by tumor. Histology: Malignant leiomyoblastomna of the stomach moderately differndated, infiltrating the full thickness of the gastric wall and reaching the serosa. Patient had Uneventful post- operative recovery, she was discharged on the 7th post- operative day; At two years follow up, patient was free of recurrence