Presentation on theme: "HPI Timeline Signs and Symptoms Implication"— Presentation transcript:
1HPI Timeline Signs and Symptoms Implication 2 years, 3.5 mo PTC (Mar 2008)chronic coughTBloss of appetiteweight lossafternoon feverbody malaiselocal HC in Cainta: CXR, sputum exam1 year, 8.5 mo PTCrepeat CXR, claimed cleared, no records availableResolution of TB?
2HPI Timeline Signs and Symptoms Implication 8 months PTC (Feb 2010) tolerable colicky abdominal painInvolvement of a hollow organbloatednessInvolvement of more distal segments of intestinesabdominal distentionHallmark of intestinal obstruction;relieved by passage of flatus or stoolNot obstipated, partial obstruction
3HPI Timeline Signs and Symptoms Implication 4 weeks PTC vomiting of ingested food ~1-2x/weekObstructionincreased frequency andseverity of abdominal distentionProgressive cause of obstructioncolicky pain localized @ RLQPossible locationsChronicity rules out appendicitisanorexiaMalabsorption, malnutritionlost 20-30% weight
4HPI Timeline Signs and Symptoms Implication 18 days PTC menses Rules out pregnancy as cause of vomiting, colicky pain(Ruptured ectopic pregnancy can present as intestinal obstruction)
5HPI Timeline Signs and Symptoms Implication On admission stable vitals BP, HR and RR important indicators of compensatory responses to a hypovolemic status.37.8 degrees Celsius is the cut-off point for normal expected temperature in cases of obstructionambulatoryevidence of muscle wastingMalabsorption, malnutritionhypostheniaminimally worked up and diagnosed but cannot be cleared for intervention due to pulmonary complications
6Primary Impression: GI Tuberculosis History of pulmonary tuberculosis with undocumented resolutionAbdominal pain localized at the right lower quadrantSigns and symptoms of obstructionBloatednessAbdominal disentention relieved by passage of flatus or stoolVomitingAnorexiaProgressive
7Gastrointestinal Tuberculosis Gastrointestinal Tuberculosis is the 6th most common extrapulmonary manifestation of tuberculosis (Chong and Lim 2009)Any site of the GI tract may be involved although studies show a predilection to the ileocecal segments (Fauci et al, 2008).increased density of lymphoid tissueincreased stasisneutral luminal pHabsorptive transport mechanismsroute of infectionpenetration of the bowel wallhematogenous dissemination
8Gastrointestinal Tuberculosis and its Correlation with Pulmonary Tuberculosis 25% of gastrointestinal TB cases have evidence of pulmonary TBthere is a direct correlation between the severity of pulmonary infection with the presence of GI infectionWith minimally advanced pulmonary disease, 1% of patients have a concomitant GI infectionmoderately advanced cases of pulmonary TB, 4.5% have evidence of GI TB25% of patients with severely advanced PTB cases have concomitant GI TB while55% to 90% of fatal cases have GI involvement.Hamer et al 1998
9Gastrointestinal Tuberculosis Manifestations Ulcerative formmajor form associated with increased pathogenicity and mortalityappears as superficial ulcerative lesions on the epithelial surface.Hypertrophic formscarring, fibrosis and mass formation resembling carcinomatous lesions.Ulcerohypertrophic formcombination of the first two with both ulcerations and scar formationThe host’s immune system plays a major role in determining the presentation.Those with depressed immune responses are likely to develop the ulcerative form while those with competent immunologic responses would present with a hypertrophic form of the disease (Chong and Lim. 2009).Hamer et al 1998
12Differential Diagnoses Mechanical causes of obstructionherniations, volvulus and intussusceptions are ruled out on physical exam and barium studies performed on the patientadhesions secondary to previous surgery are unlikely as there is no mention of it in the patient’s historyAdynamic ileus and colonic pseudo-obstruction are ruled out as colicky pain is absent in both conditionsFauci 2008
13Differential Diagnoses Causes of RLQ painAppendicitis, ruled out by the duration of illness.Right-sided diverticulitisless prevalent form of diverticulitis.clinical manifestation includes abdominal tenderness, nausea, emesis, anorexia and GI bleeding (Nirula and Greaney, 1997)Obstruction secondary to scarring from an infectious process can be a complication of this diseaseExaminations for ruling out this disease include a complete blood cell count, urinalysis, and flat and upright abdominal radiography.Further examinations include CT imaging studies, abdominal radiography with contrast and endoscopy (Roberts et al 1995).
14Differential Diagnoses Causes of RLQ painGastroenteritis and inflammatory bowel diseaseboth do not present with obstructive symptomslack of diarrhea in the patientlack of cobblestoning on radiographic studies rules out inflammatory bowel disease, particularly Crohn’s disease.
15Differential Diagnoses Causes of RLQ painGynecologic causes of right lower quadrant pain such as ovarian tumor or torsion, and pelvic inflammatory disease as well asRenal causes such as pyelonephritis, perinephritic abscess and nephrolithiasis are ruled out as they do not present with obstructive symptoms.
16Differential Diagnoses TB peritonitisuncommon extrapulmonary manifestationa consideration in patients presenting with several weeks of abdominal pain, fever, and weight loss.Ruled out because of the lack of ascites, a major feature arising from the exudation of proteinaceous fluid from the tuberclesRuptured tubal pregnancy presenting as intestinal obstruction is unlikely as the patient reports recent menstruation
17ManagementAlleviation of symptoms of distention via nasogastric decompressionCorrection of nutritional statusResection of the involved tissueDemonstration of organism via culture of resected segment followed by sensitivity testingAnti-mycobacterial treatment using appropriate medications
18ManagementAlleviation of symptoms of distention via nasogastric decompressionCorrection of nutritional statusserves to prepare the patient for surgical interventionmonitoring of serum albumin
19Management Resection of the involved tissue obstruction is a leading indication for surgery in intestinal tuberculosisother indications for surgery include ulcerative complications such as free perforation, perforation with abscess, or massivePreoperative drug therapy is still controversialTownsend et al 2008Sharma and Bhatia 2004
20Management Resection of the involved tissue right hemicolectomy with a 5 cm margin with anastomosisan ileostomy and a mucous fistula with subsequent anastomosisTownsend et al 2008Sharma and Bhatia 2004
21ManagementDemonstration of organism via culture of resected segment followed by sensitivity testingdefinitive diagnosis of mycobacterial infection by acid-fast stain or culturePCR methodsculture and sensitivity to determine which drugs are still effective
22Management Anti-mycobacterial treatment using appropriate HRZES RCT: standard 6 month course vs prolonged courses of conventional TB medication shows no significant difference in cure ratesSharma and Bhatia 2004