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

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

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