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بسم الله الرحمن الرحيم

بسم الله الرحمن الرحيم. Right Lower Quadrent Pain And Mass. Presented by: 1. Ali d. al-ghamdi. 2. Dhafer a. al-shah rani. 3. Ibrahim Qaisi. Right Lower Quadrent Pain And Mass:. Acute RLQ pain. Chronic RLQ pain. Right Iliac Fossa Swelling. Small bowel. Ascending colon.

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بسم الله الرحمن الرحيم

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  1. بسم الله الرحمن الرحيم

  2. Right Lower Quadrent Pain And Mass Presented by: 1. Ali d. al-ghamdi. 2. Dhafer a. al-shahrani. 3. Ibrahim Qaisi.

  3. Right Lower Quadrent Pain And Mass:

  4. Acute RLQ pain Chronic RLQ pain

  5. Right Iliac Fossa Swelling Small bowel Ascending colon

  6. Groin Swelling

  7. Work up of Abdominal Pain History History – Onset – Qualititive description – Intensity. – Frequency. – Location (Does it go anywhere? Referred? – Duration ? – Aggravating and Alleviating Factors

  8. Laboratory Tests – Urine analysis – Urine Pregnancy – CBC – Chem, LFT, - depending on differential Physical Examination Physical Examination – Inspection – Palpation ,Percussion – rebound tenderness – Guarding - Auscultation – Rectal Exam – Pelvic Exam Diagnostic studies – Plain Films – Ultrasound – Ct Scan

  9. Acute appendicitis

  10. Clinical Aresentation of Appendicitis -          Symptoms o         Classical presentation is of a central Colicky abdominal pain which localises to McBurney's point. The central abdominal pain, is visceral and midgut in origin (hence the umbilicus), and the localisation is caused by local peritoneal irritation in the RIF  o         Associated symptoms: Nausea, vomiting, anorexia. -In infants : diarrhoea & vomiting may be the only symptoms.

  11. YET NOT ALWAYS SO “” CLASSIC - 40% of patients present atypically. - Atypical presentation more likely if extremes of age, pregnant immunocompromised, or atypical anatomical location of appendix.

  12. O/E • o        General   tachycardia   Fever (low grade) • o         Abdomen        -Tenderness and guarding at McBurney’s point – the junction of the middle and outer thirds of a line which joins the umbilicus to the ASIS   -Rovsing’s Sign: Pressure applied in LIF causes increased pain in the RIF    -Rebound tenderness

  13. Investigations : Diagnosed clinically (usually) WBC elevated X-ray if ureteric colic is suspected US for females to role out ovarian pathology

  14. Treatment & Complication appendectomy with prophylactic metronidazole by suppository should be given 1hour preoperatively to reduce the risk of wound infection. - Complication : 1- appendicular mass : Omentum & small bowel adhere to inflamed appendix Rx: conservative ( IV fluid , analgesics , cefuroxime , metronidazole ) if the mass resolved carry out an interval appendectomy after 3 months if it gets bigger , it is likely that an appendicular abscess has formed 2- appendicular abscess : CT to diagnose it Rx: drainage and appendectomy or percutaneous drainage under US or CT control &interval appendectomy is required subsequently .

  15. Meckel’s diverticulum • The rule of 2's: • -    occur in 2% of the population • - symptomatic in 2% of cases • -    2 feet from the ileocaecal valve (60cm) • -    2 inches in length (5 cm) • -    2:1, males:females • -    2 types of mucosa, gastric and intestinal(or pancreaatic). • - 2 presentations ( bleeding & obstruction )

  16. Clinical feature • Vary greatly and may be noted as an incidental finding. However the Meckel’s may present with: • -     Acute diverticulitis  ” mimic appx” • -     Intussusception • -     Small bowel obstruction • -     Perforation • -     'Gastric' ulcer type picture (ectopic peptic ulcer on mesentric border of adjacent ileum), due to the presence of gastric mucosa cells; Abdo pain and small-bowel bleeding . - Confirmation of Dx : 99mTc sodium pertechnetate.

  17. Management • Asymptomatic: = Incidental finding - if in Children: - Generally removed as a precaution - if in Adults: - Generally left in situ. • Symptomatic: = Acute diverticula - Treat as in diverticulitis ’according to complication they cause’.

  18. Crohn`s disease

  19. Epidemiology Crohn’s disease (CD) is a chronic relapsing inflammatory condition usually with flare-ups alternating with periods of remission, and an increasing disease severity and incidence of complications as time goes on. It can affect any part of the gastrointestinal tract from the mouth to the anus. For typical sites & proportion of patients affected see below: Extensive Small Bowel – 5% Terminal Ileum only – 20% Ileocaecal – 45% Colon only – 25% Other: anorectal, gastroduodenual, oral only – 5%

  20. - The incidence is lower in non-white races. - The incidence is rising. - Bimodal age distribution:20-40 yrs/60-80 yrs - Females are affected more than males 1.2:1

  21. Pathology It is characterised by patchy transmural inflammation. There is an increased permeability ingut epithelium which allows antigens into the tissues. The chronic inflammatory process leads of thickening of the bowel wall and can cause a narrowed lumen. In early CD there are prominent lymphoid follicles followed by aphthoid ulceration. Later this progresses to larger deep fissuring ulcers separated by normal looking mucosa (cobble-stoning), fibrosis, stricturing and fistulation. These changes are often segmentally distributed (skiplesions).

  22. Some of the complications of CD are outlined below: Fistula formation – abnormal channels of communication can form in CD between loops of bowel, bladder and skin. If the CD is in the colon, fistulae can form between the colon and vagina or between the colon and perineum. The diagram on the right shows the beginning of a fistula formation with a fissure extending though mucosa towards the muscular wall. Below is a representation of a fistula starting from an area of ulceration Obstruction - typically occurs from strictures or adhesions which narrow the lumen, blocking the passage of the intestinal contents. This can be seen in the barium follow-through to the right.

  23. Aetiology & Pathogenesis

  24. Clinical Features The clinical presentation can be very variable depending upon the site and predominant pathology of that site. Major symptoms include: Diarrhoea (can be bloody with colonic involvement, or steatorrhoea in small bowel disease) Abdominal pain Weight loss Constitutional symptoms such as malaise, anorexia, nausea, vomiting and a low grade fever. To make things more complicated – 15% of patients have no gastrointestinal symptoms at all! CD here can sometimes present as an emergency with acute right iliac fossa painwhich mimics appendicitis. Cohn's colitis Similar to ulcerative colitis but less blood in the diarrhoea. Extra-intestinal features are more common in CD of the colon “crohn’s colitis” than CD of the small bowel.

  25. Intestinal Complications • Anal and perianal complications • Fissure in ano or fistula in ano • Haemorrhoids • Skin tags • Perianal or ischiorectal abscess • Anorectal fistulae • Cancer • With Crohn’s colitis, there is a increased risk of colorectal carcinoma • There is an small increased risk of rarer small intestinal and anal cancers occurring in cites of prolonged inflammation.

  26. Extra-intestinal complications There are many systemic associations and complications of CD, most affecting the liver and biliary tree, joints, skin and eyes: Sclerosing Cholangitis – occurs in a small proportion of patients. The pathogenesis is unknown and the condition is characterised by an inflammatory obliterative fibrosis of the biliary tree (the white in the diagram->). It progresses slowly and a liver transplant is the only cure. Ankylosing spondylitis – affects about 5% of patients with Crohn’s colitis. The patient presents with back pain and stiffness and the diagnosis can come years before the CD.

  27. Extra-intestinal complications Erythema nodosum – occurs in ~8% of Crohn’s colitis patients when disease is active. Hot, red tender nodules appear on the arms and legs and subside after a few days. Pyoderma gangrenosum – occurs in ~2% of CD patients, starting as a small pustule, then developing into a painful, enlarging ulcer, most commonly on the leg. In addition to these conditions, other complications and associations include episcleritis and uveitis (occuring in 5% of patients with active disease), osteoporosis (as a consequence of chronic inflammation, malabsortion and treatment with corticosteroids) and arthropathy.

  28. Diagnosis and Management Radiology and imaging Barium follow-through – findings consistent with Crohn’s include an asymmetrical alteration in mucosal pattern with deep ulceration and areas of narrowing or stricturing. Colonoscopy, terminal ileoscopy & biopsy: These allow direct visualisation and allows for a biopsy of the mucosa to be taken. This is central to macroscopic and microscopic diagnosis. Ultrasound & CT scanning: Can help define thickness of the bowel and mesentery and can be useful to evaluate disease progress & chart fistula formation.

  29. Blood tests Haematology: results suggesting anaemia,  platelet count &  ESR suggests an inflammatory bowel condition. Biochemistry:  C-reactive protein and  serum albumin suggests active CD. Liver biochemistry may be abnormal. Stool cultures Faecal calprotectin: provides accurate marker of inflammatory activity. Calprotectin is a neutrophil-derived cytosolic protein that is resistant to bacterial degradation and if present in the stools provides an accurate index of intestinal inflammatory activity. It is not routinely available but has the potential to be a simple, cheap, non-invasive marker. Stool cultures should be done to rule out infection as a differential diagnosis.

  30. Management Treatment depends upon the disease activity and site but should also be tailored to the clinical presentation and underlying pathology. The aim in to induce and maintain remission. Risk factors outlined earlier (such as smoking) should be avoided Diarrhoea can be controlled by anti-diarrhoeals. The drugs most commonly used to induce remission are aminosalicalates, corticosteroids (oral), Infliximab and Methotrexate. Surgery is indicated for perforation or haemorrhage (emergency) or for small-bowel obstruction, Crohn's colitis, abscess (intra-abdo and perianal), fistulas and inflammation unresponsive to medical therapy. Approximately 80% of patients with CD will require surgery at some point. Surgery is not curative. The surgery most applicable for small bowel CD is resection “ end-to-end anastomosis” whereas for colonic involvement the most suitable surgical options are segmental or subtotal colectomy.

  31. summary of crohn’s dis. The clinical presentation and subsequent treatments depend upon the site of inflammation and the type of pathology underlying it. For example, the most common site is the ileocaecal area which presents typically with pain and/or tender mass in right iliac fossa with or without diarrhoea and weight loss. On the other hand oral CD presents with mouth ulcers and induration. Recurrence : The rate is high either early or late . 40% within 5 years 60% within 10 years 75% within 15 years

  32. Carcinoma of caecum and right colon

  33. Epidemiology • Colon(+rectum) cancer is the 3rd most common cancer after breast and lung. F>M Pathophysiology: majority are adenocarcinoma ** Pathological features -          Site • o        Rectum 57% • o        Sigmoid 21% • o        Caecum 6% • o        Trans Colon 5% • o        Asc colon 3% • o        Splenic flexure 3% • o        Hep flexure 2% -          Synchronous lesions o        Up to 3% of patients have one or more synchronous cancers

  34. Risk factor: 6-          Genetic factors o        FAP o        Hereditary non-polyposis colon cancer (HNPCC) accounts for about 10% of colon malignancies. 2-3x increased risk if first degree relative with adenocarcinoma o        1/10 Ashkenazi Jews carrying a fault gene. 7-          IBD o        UC o        Crohn’s 4x risk of CRC 1-          Age: 80% diagnosed after 60 years of age 2-          Previous history of CRC 3-          Dietary factors o        Bile salt conversion: A suggested theory of diets being high in bile salts leading to conversion by bacteria to carcinogens o        Reduced intake of fibre: Slows transit increasing the time of exposure of the mucosa to carcinogens 4-          Adenomatous polyps 5-          Family history

  35. **** Symptoms associated with colon ca: • -          Change in bowel habit • -          PR bleed(occult in feces) and/or mucus • -          Abdominal pain • -          Malaise • -          Weight loss • -          Anaemia • -          Tenesmus o        specific to Right sided tumours (in relation to left) §          Non specific complaints: • ·          Malaise • ·          Weight loss • ·          Non-specific abdominal pain(late; dull ache) • ·          ?Mass in abdomen • ·          ?Iron deficiency anaemia • . Acute appx if tumour block the mouth of the appx causing it to dilate.

  36. On examination • -          Usually unremarkable • -   general appearance: pale & thin. • - tenderness in RIF • - irregular mass. • - dull in percussion. • -normal bowl sound unless obstruction or peritonitis.

  37. Investigation - Stool: +ve for occult blood. - Blood film: iron def. anaemia. - Barium enema: apple core lesion’ or Constrictions or intraluminal mass. - Colonoscopy : o  Investigation of choice oDirect observation of whole colon -  Tumour marker o        CEA {carcinoembryonic antigen}should be used as marker for elimination or recurrence and not in the diagnosis [raised] - ESR: raised

  38. Staging -          Duke Stage A: Confined to mucosa o        90% 5 year survival -          Duke Stage B: Extended through muscle layers and possibly reached serosa o        60% 5 year survival -          Duke Stage C: B + lymph node mets o        30% 5 year survival -          Duke Stage D: Disseminated metastatic disease o       less than 5% 5yrs survival.

  39. Management o        Rx of Dukes A to C disease is primarily by surgicalremoval, and this is accompanied in B and C by adjuvant therapy. §          Right-sided tumours – Right hemi-colectomy. o        Advanced disease -          Local disease and recurrence o        When disease progression is extensive the cancer may be debulked using a combination of chemotherapy and radiotherapy in order to reduce symptoms . -          Hepatic mets o        Solitary hepatic mets may be suitable for resection

  40. After surgery

  41. شكرًا والسلام عليكم ورحمة الله وبركاته

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