Cases of infiltrative intraabdominal mass MGR Division of Gastrointestinal hepatology R2 이홍주 / Prof. 김효종

Case I

3  Chief Complaint LLQ pain remote onset : 내원 일주일 전 recent onset : 내원 당일 아침  Present Illness 특이병력 없는 자로 내원 일주일 전부터 anorexia, LLQ pain 발 생하여 내원 3 일 전 개인병원 방문하여 약물 치료받았으나 증상 지속되고, 내원 당일 아침 증상 더욱 악화되어 further evaluation 및 management 위해 ED 경유 입원 빈 O 선 F/44 Adm via ER dull → sharp & cramping 식사와 상관없이 발생 radiating pain (-) slowly progression worsened by movement

4  Past medical history DM / HTN / Tb / Hepatitis ( - / - / - / - ) Op Hx(-) Food Hx (+) 쌀밥, 나물류, 최근 10 일간 육류 (-), 어류 (-) OBGY Hx Mensturation : duration – for 6~7days interval – 28 days(regular) amount – 3 pad/day dysmenorrhea (-) IUD insert (15 년전, local)  Personal history Smoking (-) Alcohol (-) Occupation : 주부  Family history 어머니 : HTN

5 Review of System General fever(-) chill(-) fatigue(+) weight loss(+) : 5kg for 1month Skin rash(-) pigmentation(-) itching(-) Head & Neck headache(-) dizziness(-) Eye & ENT visual disturbance(-) hoarseness(-) sore throat(-) rhinorrea(-) nasal obstruction(-) otorrhea(-) otalgia(-) Respiratory cough(-) sputum(-) dyspnea(-) tachypnea(-) Cardiac chest pain(-) palpitation(-) orthopnea(-)

6 Review of System Gastrointestinal A/N/V/D/C(+/-/-/-/-) abdominal pain(+) : LLQ melena(-) hematochezia(-) hematemesis(-) Urinary Urinary dysuria(-) frequency(-) nocturia(-) flank pain(-) residual urine sense(-) Gynecologic amenorrhea(-) vaginal discharge(-) Musculoskeletal myalgia(-) weakness(-) back pain(-) Neurologic syncope(-) dizziness(-) syncope(-)

7 Physical Examination V/S 110/90 – 88 회 /min – 20 회 /min – 36.0°c Height 156cm Weight 48kg BMI 19.7 General alert consciousness mentality acutely ill looking appearance Skin no rash no pigmentation Head & Neck no neck vein engorgement no cevical LN enlargement Eye & ENT isocoric pupil with PLR (++/++) pinkish conjunctiva clear sclera PI (-/-) PTH (-/-)

8 Physical Examination Thorax clear breathing sound without crackle, wheezing regular heart beat without murmur Abdomen rigid and flat abdomen normoactive bowel sound abdominal tenderness : LLQ rebound tenderness : LLQ muscle guarding : LLQ no palpable mass no abdominal bruit no splenomegaly no hepatomegaly Anus & Rectum no hemorrhoid no active bleeding brown colored stool Back & Extremities CVA tenderness (-/+) : Lt pretibial pitting edema (-/-)

9 Initial Lab FindingsCBC/DC 22050/mm² g/dl – 37.1% - 534K (seg 83.3%) aPTT 34.3 sec PT (INR) 13.6 sec (1.05)Chemistry TB/DB 0.45/0.16 mg/dL AST/ALT 13/18 IU/L ALP/GGT 78/79 IU/L Prot/Alb 6.2/3.7 g/dL BUN/Cr 9/0.6 mg/dL Ca/P/Mg 8.3/3.7/1.9 mg/dL Na/K/Cl 139/3.8/103 mmol/L CRP 6.8mg/dL LD/CK 375/19U/L ESR 42mm/hr T-chol/uric acid 119/2.7 mg/dLU/A RBC 0~1/HPF WBC 0~1/HPF Occult Blood (-) Protein (-) Glucose (-) Nitrite (-) Stool exam Helminth (-) Protozoa(-) Occult blood (-)

10 Chest x-ray

11 Simple abdomen Supine Erect

left lower quadrant American Family Physician 2008 ; 77(7) :

LLQ pain, Cramping Slow aggravation for several days Peritoneal irritation sign Leukocytosis Diverticulitis c peritonitis

14 Initial assessment 1. Diverticulitis with peritonitis R/O Colitis, IBD, IBS, Malignancy R/O Colitis, IBD, IBS, Malignancy R/O Torsion of Ovarian mass R/O Torsion of Ovarian mass R/O PID R/O PID R/O Acute pyelonephritis R/O Acute pyelonephritis R/O Neprolithiasis R/O Neprolithiasis

Figure 4. Algorithm for the evaluation of left lower quadrant abdominal pain American Family Physician 2008 ; 77(7) :

16 Plans Diverticulitis with peritonitis R/O Colitis, IBD, IBS, Malignancy R/O Colitis, IBD, IBS, Malignancy R/O Torsion of Ovarian mass R/O Torsion of Ovarian mass R/O PID R/O PID R/O Acute pyelonephritis R/O Acute pyelonephritis R/O Neprolithiasis R/O Neprolithiasis Plan) Abdominal CT, tumor marker Culture for blood & urine Antibiotics start (Ceftriaxone + Metronidazole)

Abdomen CT

Operative record Date : Date : Pre-operative diagnosis : T-colon diverticulitis c perforation Pre-operative diagnosis : T-colon diverticulitis c perforation Post-operative diagnosis : Intraabdominal inflammation Post-operative diagnosis : Intraabdominal inflammation Name of operation : T-colon segmental resection Name of operation : T-colon segmental resection & small bowel segmental resection & small bowel segmental resection Procedure & finding Procedure & finding - GA : lithotomy position - Lesion T-colon : Intraabdominal inflammation T-colon : Intraabdominal inflammation Small bowel & peritoneum 과 adhesion Small bowel & peritoneum 과 adhesion Mass like lesion 보임 ( 약 6X6cm) Mass like lesion 보임 ( 약 6X6cm) Dissection 중 pus 나옴 Dissection 중 pus 나옴 Small bowel 과 dissection 불가능 : jejunum 약 15cm segmental Small bowel 과 dissection 불가능 : jejunum 약 15cm segmental resection. Functional end to end anastomosis resection. Functional end to end anastomosis

Pathology

Final Diagnosis #1. Peritonitis #1. Peritonitis d/t abdominal actinomycosis d/t abdominal actinomycosis 30

Clinical course Admission Opration Pathology Discharge 3/15 3/17 4/23/20 Ceftriaxone + Metronidazole IV Ampicillin +Sulbactam P.O. Amox +Clavulanate

Case II

33 Chief Complaint RLQ pain onset : 내원 4 개월 전 Present Illness 내원 4 개월 전 시작된 RLQ pain 으로 원자력병원에서 EGD, CSF, abd CT 시행하였으나 특이 소견 없었으며 약물 치료받았으나 증상 지속되고 최근 변이 가늘어지는 증상 동반되어 입원. Past medical history Past medical history DM / HTN / Tb / Hepatitis ( - / - / - / - ) Op Hx(-) 한 O 수 M/55 Adm via OPD Dull, continous 식사와 상관없이 발생 radiating pain (-)

34 Review of System General fatigue(-) fever(+:intermittently) chill(-) weight loss(-) GI A/N/V/D/C (-/-/-/-/+) abdominal pain (+) : NPO state Physical Examination V/S 120/80 – 78 회 /min – 20 회 /min – 36.0°c General alert consciousness mentality chronic ill looking appearance Abdomen soft and flat abdomen Normoactive bowel sound no abdominal tenderness ← RLQ:4 개월 전 no rebound tenderness ← RLQ:4 개월 전 no muscle guarding CBC/DC 11520/mm² g/dl –33.1% - 744K (seg 84.3%) CRP 3.2mg/dL ESR 98mm/hr CA U/mL AFP 2.52ng/mL CEA 1.32ng/mL CA U/mL AFP 2.52ng/mL CEA 1.32ng/mL Initial Lab Findings

Abdominal CT ( )

Colonoscopy ( )

Pathology

Abdominal CT ( )

Admission Discharge Clinical course 8/25 9/10 10/14 1/28 11/25 3/19 Amoxicillin/Clavulanate Penicillin 300 만 IU q 4hrs 8/26 9/9

Case III

41 Chief Complaint Lower abdominal pain onset : 내원 40 여일 전 Present Illness 내원 40 여일 전 시작된 Lower abdominal pain 으로 local clinic 방 문하여 약물 치료받았으나 증상 지속되어 내원 3 일전 원주 의료원 에서 colon study 시행하였으며 colon mass 소견 보여 입원. Past medical history Past medical history DM / HTN / Tb / Hepatitis ( - / - / - / - ) Op Hx(+) : C/Sec – ’87, ’89 IUD insert – 10 년 전 원 O 순 F/42 Adm via OPD Dull, continous 식사와 상관없이 발생 radiating pain (-)

42 Review of System General fatigue (-) fever(+) chill(-) weight loss (+) : 6kg loss GI A/N/V/D/C (-/-/-/-/+) abdominal pain (+) : Lower V/S 110/70 – 96 회 /min – 20 회 /min – 37.9°c General alert consciousness mentality acutely ill looking appearance Abdomen soft and flat abdomen abdominal tenderness : LLQ no rebound tenderness / muscle guarding Physical Examination Initial Lab Findings CBC/DC CBC/DC 14880/mm² g/dl – 28.5% - 434K (seg 87.3%) CRP 9.8mg/dL ESR 74mm/hr AFP 1.25ng/mL CEA 2.62ng/mL

Sigmoidoscopy

Abdominal CT ( )

Abdominal CT ( )

Clinical course /10 6/ / /19 Ampicillin/Sulbactam 7/3 Stent insert /12 Endoscopic Bx : Chr inf /11 6/30 Admission 8/4 Discharge Endoscopic Bx : Chr inf Sig:colon ca IUD remove