Orthostatic hypotension is very common in the elderly. It increases morbidity and is an independant predictor of all cause mortality. It is defined as a fall in systolic blood pressure greater than 20 mm Hg or a fall in diastolic blood pressure greater than 10 mm Hg within 3 minutes of standing. Symptoms include light headedness, weakness, blurred vision, fatigue and lethargy and falls. Most patients have orthostatic hypotension due to non neurogenic causes. Drugs like antihypertensives and tricyclic antidepressants are very common causes of orthostatic hypotension. Diagnosis is based on the history and a thorough clinical examination. Based on the history and physical examination, further testing of the heart, kidneys and autonomic nervous system may be required in selected patients. Non pharmacological methods like slow position change, increased fluid and sodium intake, compression stockings and elevation of head of the bed are the key to management of orthostatic hypotension. After these methods, pharmacological treatment with fludrocortisone and midodrine should be tried. Other drugs like desmopresin acetate, xamoterol, erythropoetin and ocreotide can be used as second line agents in selected patients.

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Multiple gastrointestinal cancers in a single patient is a rare entity. In our study, we are showing the clinical presentation and management of these patients. A fifty-nine-year-old asthenic male (already treated case of metachronous colorectal cancer in 2008 and 2011) presented with complaints of generalized weakness and fatigue. Strong family history was present with two of his first-degree relatives having diagnosed with gastrointestinal cancer at the age < 50 years with one of them having stomach carcinoma and another with GEJ tumors. On evaluation, upper GI endoscopy revealed growth at cardia and endoscopic biopsy revealed adenocarcinoma. Radiological evaluation with PET-CT scan revealed proximal stomach growth with regional lymphadenopathy. Patient was optimized for surgery and underwent D2 total gastrectomy, distal pancreatectomy and splenectomy with Roux-en-Yoesophago-jejunal anastomosis. Pathological stage revealed pT4N2M0, moderately differentiated adenocarcinoma of proximal stomach, both distal and proximal cut margins negative for tumor, LVI present with no perineural invasion, and 5/18 lymph nodes dissected were positive for malignancy. Genetic testing needs to be considered in this patient (modified Bethesda guidelines and IGCLC criteria). Familial gastric cancer are of two types: (a) hereditary diffuse gastric cancer syndrome, (b) familial intestinal type gastric cancer. Approximately 5% of patients have germ-line mutations-AD LYNCH syndrome, hereditary breast-ovarian cancer, and polyposis and non-polyposis syndrome. Once diagnosed in localized advanced stage, the best treatment is R0 resection though overall prognosis in these patients is very poor. So it is rationale to find such families with elevated risk and to do active surveillance for early diagnosis and providing prophylactic gastrectomies to them as it has proven to be beneficial in hereditary form of gastric cancer.