Presentation of Gastric Adenocarcinoma with Acute Arterial Occlusive Disease, Nonbacterial Thrombotic Endocarditis and Pyogenic Liver Abscess

Gastric cancer usually presents with nonspecific signs of weight loss, abdominal pain and nausea. Physical signs are extremely rare, a palpable mass indicates an advanced status of the disease [1]. When symptoms occur the disease has most often already reached an incurable state, however it can be cured if diagnosed at early stages for instance as part of endoscopic screening programs [2]. Metastasis typically involves the lymph nodes, “per continuitatem” the tumor can spread to pancreas, liver, large and small bowel and, less frequently, to the spleen [3,4]. Diagnosis is typically made by endoscopy and biopsy. As seen by histopathology the most common type of gastric cancer is the adenocarcinoma arising from the gastric glandular epithelium either as intestinal type or diffuse type [5]. Peak incidence is usually between 50-70 years of age with a male to female ratio of around 2:1 [6]. Curative treatment remains reserved for the early non metastasized form and involves surgical removal of the tumor and varying (neo) adjuvant chemoradiotherapy protocols. Paraneoplastic phenomena are not frequent but most commonly present with acanthosis nigricans or seborrheic keratosis [7]. Another rare paraneoplastic syndrome is Trousseau’s sign of malignancy syndrome which usually presents with a hypercoagulable state and venous thromboembolism [8,9]. Trousseau (1801-1867) a professor of clinical medicine in Paris/France observed this eponymous syndrome as phlegmasia alba dolens (also called today milk leg, associated with deep vein thrombosis) on himself shortly before he was diagnosed with gastric cancer [10]. Until today, 200 years after Trousseau described the syndrome it remains poorly understood. Well-known is the association with mucin producing carcinomas of visceral origin [11]. Current research points out that Trousseau’s Syndrome (TS) is not caused by a single dysfunction but a complex interplay involving secreted mucins, elevated tissue factor expression, direct factor 10 activation and tumor hypoxia [9]. Since removing of the underlying tumor causing TS is often not possible, treatment remains symptomatic in most of the cases. Heparin is reported with the best outcome preventing coagulation in this condition [12,13]. This may be the first detailed description of a case of peripheral arterial occlusion caused by gastric cancer in the English literature to the best of our knowledge. Case Presentation