A succussion splash, Virchow's node and Sister Mary Joseph's node

Q: With the following three physical findings, what's the diagnosis, if proven otherwise?

• A succussion splash 
• A left Virchow's node
• Sister Mary Joseph's node

Answer: Metastatic gastric cancer

The objective of this question is to emphasize again the most vital art of the medicine - the physical exam.

A succussion splash is elicited by placing the stethoscope over the upper abdomen and rocking the patient back and forth at the hips. There may be a "splash" sound. It signifies Gastric Outlet Obstruction if positive after three hours of the meal. 

Virchow's node is a palpable supraclavicular lymph node, and Sister Mary Joseph's node is a palpable periumbilical lymph node.

* The author of this question highly recommends reading the case report in reference #4.

#oncology

#physical-exam

References:

1. Ferguson CM. Inspection, Auscultation, Palpation, and Percussion of the Abdomen. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 93. Available from: https://www.ncbi.nlm.nih.gov/books/NBK420/

2. Kobayashi T, Sato R, Kaneko N, Sato J, Kakugawa Y, Funayama Y. [Advanced Gastric Cancer with Virchow's Lymph Node Metastasis-A Long-Term Survival Case]. Gan To Kagaku Ryoho. 2024 Aug;51(8):821-823. Japanese. PMID: 39191712.

3. Whang TB, Wang L, Peng DH. Gastric carcinoma of the umbilicus: case report of Sister Mary Joseph nodule. Cutis. 2010 Feb;85(2):90-2. PMID: 20349683.

4. Fill S, Taran A, Schulz HU, Kahl S, Kalinski T, Smith B, Costa SD. Sister Mary Joseph's nodule as the first sign of pregnancy-associated gastric cancer: a case report. World J Gastroenterol. 2008 Feb 14;14(6):951-3. doi: 10.3748/wjg.14.951. PMID: 18240358; PMCID: PMC2687068.