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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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StaffStaff ผู้��ควีบค�มผู้��ควีบค�ม นำพนำพ. . ไพศ�ล ค�ร�เสถี�ยรไพศ�ล ค�ร�เสถี�ยรณ ห้�องประช�มร'มฉั�ตร อ�ค�รเฉัล�มพระเกุ�ยรต� ณ ห้�องประช�มร'มฉั�ตร อ�ค�รเฉัล�มพระเกุ�ยรต�
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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
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
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
Acute abdominal pain
• History taking * Duration, onset, location, pattern, associated symptoms, aggravating factor, relieving factor, referred pain, ...• Physical examination * Sign of peritonitis ???
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
Acute abdominal pain
Diffuse abdominal pain
* Pancreatitis
* Early appendicitis
* Leukemia , Sickle cell llllll
* Mesenteric adenitis
* Gastroenteritis , Colitis
* Intestinal obstruction
* Metabolic cause
Differential diagnosis
Chronic abdominal pain
Acute abdominal pain
* Perforation
* Obstruction
* Ischemia
l ll lllllll*
Sudden
onset
Differential diagnosis Differential diagnosis
• Peptic ulcer perforation• Perforated CA colon ( Rt.side )• Pancreatitis• Complicated chronic cholecys
titis
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
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
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
*Minimalintraperitonealf ree fl ui d;peri toni ti s cause?
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.
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
Postoperative management
• 1 1Ceftriaxone gm iv.q 2 hr.
• llll l lll500 8
• Ti ssue for pathol ogi cal report
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
Colonic cancer ( CA colon )
CA colon• Epidemiology * 13 1Male : Female = . : * 50Age + lllll• Etiology * Polyps (Adenomatous polyps) * Diet ( fat, calories, fiber) * Inflammatory bowel disease ( ,’ ) * Genetic factor * Smoking * Others
CA colon
• lllllllll * Macroscopic - Polypoid, ulcerating, annular, infiltrative - Synchronous lesion (3 %) - 3Metachronous lesion ( %)
CA colon
• lllllllll * Histology - lllllllllllll l -1015( Mucinous adenoCA
%) - 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
l distant metastases
l
l
l
B
l
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 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
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
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
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
CA colon
• Other treatment * Adjunctive chemotherapy for patient with Dukes’ C -ll llll llllllllll! 5 - 5! FU plus levamisole ( incidence of recurrence 41%)
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
CA colon
• - 5 year survival rate - 9095Dukes’ A % - l7 5 8 0
- 4070Dukes’ C % 5Dukes’ D %
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
CA colon
• Follow up * Clinical evaluation -* Chest x ray * Colonoscopy * CEA levels
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
...ข้อบค�ณคร�บ...
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