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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.

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Presentation on theme: "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."— 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 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

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

18 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 DiseaseUlcerative Colitis Transmural involvementMucosal Disease Segmental “skip lesions”Diffuse involvement of entire colon Rectal involvement rareRectum always involved Thickened bowel wall with “creeping fat” Normal bowel all thickness Small bowel commonly effectedSmall bowel not effected except with backwash ileitis CobblestoningPseudopolyps Narrow, deeply penetrating ulcersShallow, wide ulcers Granulomas commonGranulomas 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. 8 th edition Goldman:Cecil’s Textbook of Medicine. 22 nd edition Kumar et. al. Robbin’s Basic Pathology. 7 th edition 2003 Lawrence, P. Essentials of General Surgery. 3 rd edition Townsend: Sabiston Textbook of Surgery. 17 th edition Zimmer, M. Maingot’s Abdominal Operations. 11 th edition, **Pictures courtesy of Dr. R. Steinhagen

38 Acknowledgment ASSOCIATION FOR SURGICAL EDUCATION 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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