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RLQ ABDOMINAL PAIN

RLQ ABDOMINAL PAIN. Reshma B. Patel Scott Q. Nguyen, MD Randolph Steinhagen, MD Celia M. Divino, MD Department of Surgery Mount Sinai School of Medicine New York, NY. Mr. X.

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RLQ ABDOMINAL PAIN

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  1. RLQ ABDOMINAL PAIN Reshma B. Patel Scott Q. Nguyen, MD Randolph Steinhagen, MD Celia M. Divino, MD Department of Surgery Mount Sinai School of Medicine New York, NY

  2. Mr. X A 25 year-old male presents with a 1 month history of nausea, intermittent vomiting right-sided abdominal pain, bloating, episodic diarrhea, fatigue, and weight loss.

  3. History What other information would be helpful?

  4. History, Mr.X • Characterization of symptoms • Temporal sequence • Alleviating / Exacerbating factors: • Pertinent PMH, ROS, MEDS. • Relevant family hx. • Associated signs and symptoms Consider the Following

  5. History • Pain: • Quality: Cramping and right sided • Radiation: None • Severity: 5/10 • Timing: Intermittent, coming in waves, and worse after eating. • Nausea: • intermittent w/ occasional vomiting for past month. Feels persistently bloated and distended. Appetite decreased. Hasn’t been able to eat much in past week. • Diarrhea: • Episodic watery and non-bloody. • Weight Loss: • 10 lbs over last month. Appetite decreased. Hasn’t been able to eat much in past week.

  6. History • PMH: Patient states that he has had bouts of diarrhea for years and was previously diagnosed with irritable bowel syndrome. • PSH: Laparoscopic Cholecystectomy 2000 • Meds: None • Family Hx: Grandfather died from colon cancer • Social Hx: No tobacco, alcohol, or drug use. Traveled to Mexico 2 months ago

  7. Differential Diagnosis • Irritable Bowel Syndrome • Partial Small Bowel Obstruction • Appendicitis • Diverticulitis • Infectious diarrhea (Salmonella,Shigella,Campylobacter, TB) • Parasitic infection (amebic infection) • Celiac Sprue • Ulcerative Colitis • Crohn’s Disease • Pseudomembranous Colitis • Intestinal Lymphoma • GI Malignancy • Mesenteric Adenitis

  8. Physical Exam • Vitals-Temp: 39 C BP: 105/65 HR: 100 RR:15 • Gen: Thin appearing male. • Cardiac: S1,S2. RRR. No murmurs, gallops, or rubs • Lungs: CTAB. No wheezes, rales, or rhonchi • Abdomen: Soft, somewhat distended, mildly tender to palpation worse in the right lower quadrant. Palpable mass in right lower quadrant. Bowel sounds hyperactive. No organomegaly. No guarding or rebound. • Rectal: Sphincter tone normal. Perirectal erythema and tenderness. Anal fissure noted at 3 o’clock position. Heme positive. • Musculoskeletal: Normal range of motion in all four extremities. • Extremities: No erythema or edema.

  9. Review of Systems Non-contributory except for: • Gen: fever, fatigue, and weakness x 1 month; 10 lb weight loss over last month • GI:Decreased appetite with nausea for 1 month. Denies vomiting. Worsening watery, non-bloody diarrhea for 1 month.

  10. Laboratory What tests should you order? More importantly………why?

  11. Labs • CBC • Chem 7 • UA: Wnl • FOBT: Positive • Stool O & P: Negative 11 400 11 35 110 135 30 104 23 3.4 1.0

  12. Labs: Significance? • Mild Leukocytosis : ? inflammatory process • Electrolytes: hypokalemia, elevated bun/creatinine volume depletion and potassium loss • Anemia and +fobt: blood loss

  13. What’s the differential diagnosis?

  14. Irritable Bowel Syndrome Appendicitis Diverticulitis Partial Small Bowel Obstruction Infectious diarrhea (Salmonella,Shigella,Campylobacter, TB) Parasitic infection (amebic infection) Celiac Sprue Ulcerative Colitis Crohn’s Disease Pseudomembranous Colitis Intestinal Lymphoma GI Malignancy Mesenteric Adenitis Differential Diagnosis

  15. Acute Management/Interventions • Hydration / Fluid resuscitation • Correct electrolyte imbalances

  16. Imaging:Obstructive Series

  17. Imaging: Obstructive Series

  18. Imaging: Obstructive Series Your interpretation?

  19. Imaging: Obstructive Series • No free air under the diaphragm • Few dilated loops of small bowel with air fluid levels in the Left abdomen • Some air noted in colon • Consistent with partial small bowel obstruction

  20. What test next?

  21. Imaging: Small Bowel Series

  22. Small bowel series: Interpretation Narrowing of the terminal ileum with multiple strictures. Mass at RLQ pushing remaining small bowel aside.

  23. Colonoscopy • Colonic mucosa normal appearing • Difficultly traversing the ileocecal valve • Terminal ileum beefy and red with linear ulcerations adjacent to normal appearing mucosa with a cobblestone appearance • Biopsies taken

  24. Biopsy Results • Inflammation with neutrophilic infiltration into epithelial layer and accumulation into crypts forming crypt abscesses • Scattered lymphoid aggregates throughout the tissue layers • Non-caseating granulomas • Ulceration • Chronic mucosal damage with architectural distortion and atrophy

  25. What’s the Diagnosis?

  26. Crohn’s Disease • The first line treatment for Crohn’s Disease is medical therapy Asymptomatic or Minimally Symptomatic Disease: • 5-ASA compounds (sulfasalzine, mesalamine): topically affects bowel in reducing inflammation • Antibiotics: ciprofloxacin and metronidazole Moderate to Severe Disease • Corticosteroids: potent anti-inflammatory agent for refractory cases and acute flares • Immunomodulators: (azathioprine, methotrexate, infliximab) modulate immune system / immune cells active in inflammatory response

  27. When is surgical intervention warranted?

  28. Surgical Indications • Stricture • Fistula • Abscess • Carcinoma • Failed medical therapy

  29. Crohn’s Disease Creeping fat onto antimesenteric border of inflammed, thickened small bowel

  30. Specimen

  31. Surgical Technique • Creeping fat

  32. Crohn’s Features Cobblestoning

  33. Inflammatory Bowel Disease • Crohn’s disease and ulcerative colitis • Chronic inflammatory disease of the gastrointestinal tract • Incidence and prevalence vary with geographic location; more common within Jewish population • Higher rates for whites in northern Europe and North America • Incidence for each is 5 per 100,000 • Prevalence for each is 50 per 100,000 • Incidence equal in men and women • Bimodal age distribution: peak age onset between15-25yrs; second peak 55-65yrs old

  34. Crohn’s Disease: Etiology & Pathogenesis • Family history key risk factor • Infiltration of lamina propria by lymphocytes, macrophages, and other inflammatory cells • Inability to down regulate chronic inflammation of lamina propria triggered by exposure to antigens • Epithelial injury due to reactive oxygen species and cytokines

  35. Crohn’s Disease: Extraintestinal Manifestations • Apthous ulcers • Cholelithiasis • Arthritis • Skin lesions: erythema nodosum, pyoderma gangrenosum • Ocular lesions: episcleritis, uveitis

  36. References • ACS Surgery Principles and Practice • Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 8th edition 2006. • Goldman:Cecil’s Textbook of Medicine. 22nd edition 2004. • Kumar et. al. Robbin’s Basic Pathology. 7th edition 2003 • Lawrence, P. Essentials of General Surgery. 3rd edition 2000. • Townsend: Sabiston Textbook of Surgery. 17th edition 2004. • Zimmer, M. Maingot’s Abdominal Operations. 11th edition, 2004. • **Pictures courtesy of Dr. R. Steinhagen

  37. Acknowledgment The preceding educational materials were made available through theASSOCIATION FOR SURGICAL EDUCATION In order to improve our educational materials wewelcome your comments/ suggestions at: feedbackPPTM@surgicaleducation.com

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