Transcript RLQ Crohns
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 Mr. X A 25 year-old male presents with a 1 month history of nausea, intermittent vomiting rightsided abdominal pain, bloating, episodic diarrhea, fatigue, and weight loss. History What other information would be helpful? History, Mr.X Consider the Following • Characterization of symptoms • Temporal sequence • Alleviating / Exacerbating factors: • Pertinent PMH, ROS, MEDS. • Relevant family hx. • Associated signs and symptoms 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. 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 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 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. 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. Laboratory What tests should you order? More importantly………why? Labs • CBC 11 400 11 35 • Chem 7 135 110 30 3.4 23 1.0 • UA: Wnl • FOBT: Positive • Stool O & P: Negative 104 Labs: Significance? • • • Mild Leukocytosis : ? inflammatory process Electrolytes: hypokalemia, elevated bun/creatinine volume depletion and potassium loss Anemia and +fobt: blood loss What’s the differential diagnosis? 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 Acute Management/Interventions • Hydration / Fluid resuscitation • Correct electrolyte imbalances Imaging:Obstructive Series Imaging: Obstructive Series Imaging: Obstructive Series Your interpretation? 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 What test next? Imaging: Small Bowel Series Small bowel series: Interpretation Narrowing of the terminal ileum with multiple strictures. Mass at RLQ pushing remaining small bowel aside. 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 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 What’s the Diagnosis? 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 When is surgical intervention warranted? Surgical Indications • • • • • Stricture Fistula Abscess Carcinoma Failed medical therapy Crohn’s Disease Creeping fat onto antimesenteric border of inflammed, thickened small bowel Specimen Surgical Technique • Creeping fat Crohn’s Features Cobblestoning 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 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 Crohn’s Disease Ulcerative Colitis Transmural involvement Mucosal Disease Segmental “skip lesions” Diffuse involvement of entire colon Rectal involvement rare Rectum always involved Thickened bowel wall with “creeping fat” Normal bowel all thickness Small bowel commonly effected Small bowel not effected except with backwash ileitis Pseudopolyps Cobblestoning Narrow, deeply penetrating ulcers Shallow, wide ulcers Granulomas common Granulomas rare Crohn’s Disease: Extraintestinal Manifestations • • • • Apthous ulcers Cholelithiasis Arthritis Skin lesions: erythema nodosum, pyoderma gangrenosum • Ocular lesions: episcleritis, uveitis 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 2003 • Lawrence, 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 Acknowledgment 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: [email protected]