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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..

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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:

1 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


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4 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

5 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

6 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

7 Acute abdominal pain History taking * Duration, onset, location, pattern, associated symptoms, aggravating factor, relieving factor, referred pain,... Physical examination * Sign of peritonitis ???

8 Acute abdominal pain RUQ *Biliary colic, Cholangitis, Cholecystitis *Hepatitis, Liver abscess *Peptic ulcer, Pancreatitis *Retrocecal appendicitis *Renal colic, Herpes zoster *MI, Pericarditis, Pneumonia *Empyema LUQ *Gastritis *Pancreatitis *Splenic rupture,infarction *Renal colic, Herpes zoster *Myocardial infarction (MI) *Pneumonia *Empyema RLQ *Appendicitis, intestinal obstruction, regional enteritis *Diverticulitis, Cholecystitis *PU perforation *Ectopic pregnancy, Twisted ovarian cyst, PID *Ureteric calculi, Renal colic *Psoas abscess LLQ *Diverticulitis *Intestinal obstruction *Appendicitis *Ectopic pregnancy, Twisted ovarian cyst, PID *Ureteric calculi, Renal colic *Psoas abscess

9 Acute abdominal pain Diffuse abdominal pain * Pancreatitis * Early appendicitis * Leukemia, Sickle cell crisis * Mesenteric adenitis * Gastroenteritis, Colitis * Intestinal obstruction * Metabolic cause

10 Differential diagnosis Chronic abdominal pain Acute abdominal pain * Perforation * Obstruction * Ischemia * Hemorrhage Sudden onset

11 Differential diagnosis Peptic ulcer perforation Perforated CA colon ( Rt.side ) Pancreatitis Complicated chronic cholecystitis

12 Laboratory investigation CBC :- Hb 6.9, Hct 22%, MCV 56, microcytic 1+, hypochromic 1+, poikilocytosis 1+, few anisocytosis, WBC 16,200, N 92%, L 8%, Plt.489,000 Urine exam :- , pH 5.5, no RBC, WBC 0-1, Epith. cell 1-2

13 Laboratory investigation LFT :- Alb. 3.2, Glob. 3.2, TB 0.8, DB 0.2, SGOT 16, SGPT 16, Alk.phos. 40 Serum amylase :- 67

14 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 )

15 Ultrasound of upper abdomen * Minimal intraperitoneal free fluid ; peritonitis cause ?

16 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.

17 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

18 Postoperative management Ceftriaxone 1 gm iv.q 12 hr. Metronidazole 500 mg iv.q 8 hr. Tissue for pathological report

19 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

20 Colonic cancer ( CA colon )

21 CA colon Epidemiology * Male : Female = 1.3 : 1 * Age 50 + years Etiology * Polyps (Adenomatous polyps) * Diet ( fat, calories, fiber) * Inflammatory bowel disease (Ulcerative colitis,Crohns disease) * Genetic factor * Smoking * Others

22 CA colon Pathology * Macroscopic - Polypoid, ulcerating, annular, infiltrative - Synchronous lesion (3%) - Metachronous lesion (3%)

23 CA colon Pathology * Histology - Adenocarcinoma ( Mucinous adenoCA 10-15% ) - Staging by Dukes classification and TNM classification

24 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

25 CA colon TNM classification T Tumour invasion N Lymph node M Metastases Spreading - Lymphatic, hematogenous (via veins to liver), peritoneal

26 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

27 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

28 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

29 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

30 CA colon Other treatment * Adjunctive chemotherapy for patient with Dukes C ! 5-FU plus leucovorin ! 5-FU plus levamisole ( incidence of recurrence 41% )

31 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

32 CA colon 5-year survival rate Dukes A % Dukes B % Dukes C % Dukes D 5 %

33 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

34 CA colon Follow up * Clinical evaluation * Chest x-ray * Colonoscopy * CEA levels

35 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

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