case conference a 57-year-old man with acute abdominal pain in ruq and rlq case conference a...
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Case conferenceCase conference
“ A 57-year-old man with “ A 57-year-old man with acute abdominal pain in RUQ acute abdominal pain in RUQ
and RLQ “and RLQ “
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Physical examinationPhysical examination
• T 38.8oC, 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
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Problem listProblem list
1. Acute abdominal pain in RUQ & RLQ
2. Fever3. History of chronic abdominal pain ( right side )4. History of bowel habit change5. Weight loss & decreased appetite6. Moderately pale7. Sign of peritonitis
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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 o f a careful history and physical examination
…”
Cope’s early diagnosis of the acute abdomen
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Acute abdominal pain
• History taking * Duration, onset, location, pattern, associated symptoms, aggravating factor, relieving factor, referred pain, ...• Physical examination * Sign of peritonitis ???
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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
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Acute abdominal pain
Diffuse abdominal pain
* Pancreatitis
* Early appendicitis
* Leukemia , Sickle cell llllll
* Mesenteric adenitis
* Gastroenteritis , Colitis
* Intestinal obstruction
* Metabolic cause
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Differential diagnosis
Chronic abdominal pain
Acute abdominal pain
* Perforation
* Obstruction
* Ischemia
l ll lllllll*
Sudden
onset
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Differential diagnosis Differential diagnosis
• Peptic ulcer perforation• Perforated CA colon ( Rt.side )• Pancreatitis• Complicated chronic cholecys
titis
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Laboratory investigation Laboratory investigation
• CBC -: 69 22 56Hb . , Hct %, MCV , 1 + , 1 + , poikilocytosis 1 +, fewanisocytosis, 1 6 ,2 0 0 , 9 2 % , 8 % , Plt.4 8 9 ,0 0 0
• -Urine exam : sp.gr. 1 .0 1 3 , pH 5 .5 , n o RBC,
- -01 12WBC , Epith. cell
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Laboratory investigation
• -LFT : Alb. 3.2, Glob. 3.2, TB 0.8, DB 0.2, SGOT 16, SGPT 16, Alk.phos. 40
• -Serumamyl ase : 67
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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 )
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Ultrasound of upper abdomen
*Minimalintraperitonealf ree fl ui d;peri toni ti s cause?
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Preoperative management
• Laboratory investigation• lll• 4G&M PRC units• NG intubation• 1 6Cefotaxime gm iv.q hr.• llll l lll500 8
• Set OR for Explor. Lap.
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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
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Postoperative management
• 1 1Ceftriaxone gm iv.q 2 hr.
• llll l lll500 8
• Ti ssue for pathol ogi cal report
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Pathological diagnosis
• llllll,, ; -Right half colectomy :
* - 45 4 23Signet ring CA of colon , size . x x . cm will ll lll lll lll< 5 0 %
* Tumour extends to serosa and pericolic fat
* No malignancy at the proximal and distal resected
margins
* 216Nodal metastasis ( / )
* Unremarkable ileum and appendix
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Colonic cancer ( CA colon )
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CA colon• Epidemiology * 13 1Male : Female = . : * 50Age + lllll• Etiology * Polyps (Adenomatous polyps) * Diet ( fat, calories, fiber) * Inflammatory bowel disease ( ,’ ) * Genetic factor * Smoking * Others
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CA colon
• lllllllll * Macroscopic - Polypoid, ulcerating, annular, infiltrative - Synchronous lesion (3 %) - 3Metachronous lesion ( %)
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CA colon
• lllllllll * Histology - lllllllllllll l -1015( Mucinous adenoCA
%) - Staging by Dukes’ classification and TNM classification
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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
l distant metastases
l
l
l
B
l
D
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CA colon
• TNM classification T Tumour invasion N Lymph node M Metastases• Spreading - Lymphatic, hematogenous (via veins to liver),
peritoneal
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CA colon
• Location & Clinical featurel
15%
5%10
%
20%
50
%
Right side
* Anemia (bleeding)
*Weight loss
*Right iliac fossa mass
lll lll-lllllll*
lllll llll lllll llllll lllllllllll l
llll llll *Altered bowel ha
bit
*Altered bleedingper
rectum
*13/ large bowel
obstruction
*Decrease in stool
caliber, tenesmus
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CA colon
• Clinical course - * 4070Metastases to regional LN % of lllll ll lll llll ll lllllllll * 60Venous invasion up to % of case
l l lll lll l ll llll ll l lllllllll l-*
Liver, Peritoneal cavity, Lung, Adrenal, Ovaries, Bone
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CA colon• Diagnosis * Clinical diagnosis * Biopsy confirmation * General evaluation ( PE, DRE, CBC, l -lll l, ) * Carcinoembryogenic antigen ( CEA ) screening for early recurrence * CT scan , MRI * Sigmoidoscopy, Colonoscopy , - Double contrast barium enema
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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 llllll lllllllll l llll ll llllll lll #
lesions of descending and sigmoid colon # Hartmann’s procedure for emergency to left side of colon
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CA colon
• Other treatment * Adjunctive chemotherapy for patient with Dukes’ C -ll llll llllllllll! 5 - 5! FU plus levamisole ( incidence of recurrence 41%)
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CA colon• Prognosis *Prognostic factors l lll ll lllllll l~ ( ) ~ Histologic grading ~ Anatomic location of the lll lll ~ Clinical presentation ~ Chromosome 18 - *5 year sur vi val depends on lllllll
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CA colon
• - 5 year survival rate - 9095Dukes’ A % - l7 5 8 0
- 4070Dukes’ C % 5Dukes’ D %
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CA colon
• Follow up * 85About % of all recurrence
s ar e 3evident within years after surgical resection * High preoperative CEA levels 6usually revert to normal within weeks after complete resection
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CA colon
• Follow up * Clinical evaluation -* Chest x ray * Colonoscopy * CEA levels
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l llllll l lll lllll lllll ll
Unstable or obvious surgic
al indication
llllll lllllllll
Consider :
* Hemorrhage
* Perforation
* Acute peritonitis
lllll lllllllllll*
* Ischemia
Resuscitation
Explor. lap.
l llllllllll
Consider :
Inadequate physicall llllllllllll
Further studies
Continuedlllllllllllll llll
Decreasedllll
l llllllllll Consult surgery
History,PE
Exclude medical co
ndition
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