Presentation on theme: "Case conference A 57-year-old man with acute abdominal pain in RUQ and RLQ Case conference A 57-year-old man with acute abdominal pain in RUQ and RLQ.."— Presentation transcript:
Case conference A 57-year-old man with acute abdominal pain in RUQ and RLQ Case conference A 57-year-old man with acute abdominal pain in RUQ and RLQ.. Staff. Staff
Physical examination T 38.8 o C, P 84 /min, BP 130/80 mmHg, RR 20 /min Moderately pale, no jaundice Heart & Lungs :- normal Abdomen :- mild distention, tender as figure, guarding and rigidity +ve, no palpable mass, slightly decreased bowel sounds PR :- not tender, prostate gland 3 FB, smooth surface tender
Problem list 1. Acute abdominal pain in RUQ & RLQ 2. Fever 3. History of chronic abdominal pain ( right side ) 4. History of bowel habit change 5. Weight loss & decreased appetite 6. Moderately pale 7. Sign of peritonitis
Acute abdominal pain …Even today, it remains true that the vast majority of diagnosis of patients with acute abdominal pain are still made on the basis of a careful history and physical examination… Copes early diagnosis of the acute abdomen
Acute abdominal pain History taking * Duration, onset, location, pattern, associated symptoms, aggravating factor, relieving factor, referred pain,... Physical examination * Sign of peritonitis ???
Film acute abdomen series Chest x-ray ( PA upright ) no free air Plain abdomen ( supine view ) abrupt narrowing of lumen at hepatic flexure of colon Plain abdomen ( upright view )
Ultrasound of upper abdomen * Minimal intraperitoneal free fluid ; peritonitis cause ?
Preoperative management Laboratory investigation NPO G&M PRC 4 units NG intubation Cefotaxime 1 gm iv.q 6 hr. Metronidazole 500 mg iv.q 8 hr. Set OR for Explor. Lap.
Intraoperative period Under general anesthesia (GA) Mass at hepatic flexure with perforation & few contamination Suspected metastasis to pericolic nodes Few free fluid Cul-de-sac :-free Operation :-Right half colectomy and end-to-side ileocolic anastomosis
Pathological diagnosis Ileum,cecum,appendix and colon; Right half colectomy :- * Signet-ring CA of colon, size 4.5x4x2.3 cm with mucinous component <50% of the tumour * Tumour extends to serosa and pericolic fat * No malignancy at the proximal and distal resected margins * Nodal metastasis ( 2/16 ) * Unremarkable ileum and appendix
CA colon Pathology * Histology - Adenocarcinoma ( Mucinous adenoCA 10-15% ) - Staging by Dukes classification and TNM classification
CA colon Dukes classification A confined to mucosa B1 muscle wall but not serosa B2 involves serosa C1 muscle wall+lymph nodes C2 serosa+lymph nodes D distant metastases B C A B C D
CA colon TNM classification T Tumour invasion N Lymph node M Metastases Spreading - Lymphatic, hematogenous (via veins to liver), peritoneal
CA colon Location & Clinical features 15% 5% 10% 20% 50% Right side *Anemia (bleeding) *Weight loss *Right iliac fossa mass *Dull and ill-defined abdominal pain ( rarely obstruction ) Left side *Altered bowel habit *Altered bleeding per rectum *1/3 large bowel obstruction *Decrease in stool caliber, tenesmus
CA colon Clinical course * Metastases to regional LN 40-70% of cases at the time of resection * Venous invasion up to 60% of cases * Most common site of metastases :- Liver, Peritoneal cavity, Lung, Adrenal, Ovaries, Bone
CA colon Diagnosis * Clinical diagnosis * Biopsy confirmation * General evaluation ( PE, DRE, CBC, LFT, Chest x-ray ) * Carcinoembryogenic antigen ( CEA ) screening for early recurrence * CT scan, MRI * Sigmoidoscopy, Colonoscopy, Double-contrast barium enema
CA colon Management * Surgery - Resection of the tumour with adequate margins and regional lymph nodes - Procedures # Rt.hemicolectomy (no bowel prep.) for lesions from caecum to splenic flexure # Lt.hemicolectomy (bowel prep.) for lesions of descending and sigmoid colon # Hartmanns procedure for emergency to left side of colon
CA colon Other treatment * Adjunctive chemotherapy for patient with Dukes C ! 5-FU plus leucovorin ! 5-FU plus levamisole ( incidence of recurrence 41% )
CA colon Prognosis * Prognostic factors ~ Stage ( most important ) ~ Histologic grading ~ Anatomic location of the tumour ~ Clinical presentation ~ Chromosome 18 * 5-year survival depends on staging
CA colon 5-year survival rate Dukes A % Dukes B % Dukes C % Dukes D 5 %
CA colon Follow up * About 85% of all recurrences are evident within 3 years after surgical resection * High preoperative CEA levels usually revert to normal within 6 weeks after complete resection
CA colon Follow up * Clinical evaluation * Chest x-ray * Colonoscopy * CEA levels
Patient with acute abdomen Unstable or obvious surgical indication Stable condition Consider : * Hemorrhage * Perforation * Acute peritonitis * Bowel obstruction * Ischemia Resuscitation Explor. lap. Observation Consider : Inadequate physical manifestation Further studies Continued pain Increased pain Decreased pain Observation Consult surgery History,PE Exclude medical condition