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. What other information would be helpful?
History
What other information would be helpful?

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

5. History Pain: Nausea: Diarrhea: Weight Loss:
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. What tests should you order? More importantly………why?
Laboratory
What tests should you order?
More importantly………why?

11. Labs CBC Chem 7 UA: Wnl FOBT: Positive Stool O & P: Negative 11 11 40035
135
110 30
104
3.4 23
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. Differential Diagnosis
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

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 Ulcerative Colitis Transmural involvement
Mucosal Disease
Segmental “skip lesions”
Diffuse involvement of entire colon
Rectal involvement rare
Rectum always involved
Thickened bowel wall with “creeping fat”
Normal bowel all thickness
Small bowel commonly effected
Small bowel not effected except with backwash ileitis
Cobblestoning
Pseudopolyps
Narrow, deeply penetrating ulcers
Shallow, wide ulcers
Granulomas common
Granulomas rare

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

37. 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

38. Acknowledgment
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