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, MDCelia M. Divino, MDDepartment of SurgeryMount Sinai School of MedicineNew York, NY
2 Mr. XA 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? HistoryWhat other information would be helpful?
4 History, Mr.X Consider the Following Characterization of symptoms Temporal sequenceAlleviating / Exacerbating factors:Pertinent PMH, ROS, MEDS.Relevant family hx.Associated signs and symptoms
5 History Pain: Nausea: Diarrhea: Weight Loss: Quality: Cramping and right sidedRadiation: NoneSeverity: 5/10Timing: 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 HistoryPMH: Patient states that he has had bouts of diarrhea for years and was previously diagnosed with irritable bowel syndrome.PSH: Laparoscopic Cholecystectomy 2000Meds: NoneFamily Hx: Grandfather died from colon cancerSocial Hx: No tobacco, alcohol, or drug use. Traveled to Mexico 2 months ago
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 rubsLungs: CTAB. No wheezes, rales, or rhonchiAbdomen: 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 SystemsNon-contributory except for:Gen: fever, fatigue, and weakness x 1 month; 10 lb weight loss over last monthGI: 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? LaboratoryWhat tests should you order?More importantly………why?
18 Imaging: Obstructive Series Your interpretation?
19 Imaging: Obstructive Series No free air under the diaphragmFew dilated loops of small bowel with air fluid levels in the Left abdomenSome air noted in colonConsistent with partial small bowel obstruction
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 valveTerminal ileum beefy and red with linear ulcerations adjacent to normal appearing mucosa with a cobblestone appearanceBiopsies taken
24 Biopsy ResultsInflammation with neutrophilic infiltration into epithelial layer and accumulation into crypts forming crypt abscessesScattered lymphoid aggregates throughout the tissue layersNon-caseating granulomasUlcerationChronic mucosal damage with architectural distortion and atrophy
26 Crohn’s DiseaseThe first line treatment for Crohn’s Disease is medical therapyAsymptomatic or Minimally Symptomatic Disease:5-ASA compounds (sulfasalzine, mesalamine): topically affects bowel in reducing inflammationAntibiotics: ciprofloxacin and metronidazoleModerate to Severe DiseaseCorticosteroids: potent anti-inflammatory agent for refractory cases and acute flaresImmunomodulators: (azathioprine, methotrexate, infliximab) modulate immune system / immune cells active in inflammatory response
33 Inflammatory Bowel Disease Crohn’s disease and ulcerative colitisChronic inflammatory disease of the gastrointestinal tractIncidence and prevalence vary with geographic location; more common within Jewish populationHigher rates for whites in northern Europe and North AmericaIncidence for each is 5 per 100,000Prevalence for each is 50 per 100,000Incidence equal in men and womenBimodal age distribution: peak age onset between15-25yrs; second peak 55-65yrs old
34 Crohn’s Disease: Etiology & Pathogenesis Family history key risk factorInfiltration of lamina propria by lymphocytes, macrophages, and other inflammatory cellsInability to down regulate chronic inflammation of lamina propria triggered by exposure to antigensEpithelial injury due to reactive oxygen species and cytokines
35 Crohn’s Disease Ulcerative Colitis Transmural involvement Mucosal DiseaseSegmental “skip lesions”Diffuse involvement of entire colonRectal involvement rareRectum always involvedThickened bowel wall with “creeping fat”Normal bowel all thicknessSmall bowel commonly effectedSmall bowel not effected except with backwash ileitisCobblestoningPseudopolypsNarrow, deeply penetrating ulcersShallow, wide ulcersGranulomas commonGranulomas rare
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 2003Lawrence, 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 AcknowledgmentThe preceding educational materials were made available through the ASSOCIATION FOR SURGICAL EDUCATIONIn order to improve our educational materials we welcome your comments/ suggestions at: