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RLQ ABDOMINAL PAIN Reshma B. Patel Scott Q. Nguyen, MD

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Presentation on theme: "RLQ ABDOMINAL PAIN Reshma B. Patel Scott Q. Nguyen, MD"— Presentation transcript:

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 11 400
35 135 110 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 The preceding educational materials were made available through the ASSOCIATION FOR SURGICAL EDUCATION In order to improve our educational materials we welcome your comments/ suggestions at:

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