Case Study - Srinakharinwirot...
Transcript of Case Study - Srinakharinwirot...
Case Study
• Chayamon Suwansumrit 54107010029
• Chatsaran Thanapongpibul 54107010037
• Nantanan Jengseubsant 54107010080
• Ninlaksami Chinkamolthong 54107010082
• Punnapat Yookong 54107010093
• Pattara Karnjanakan 54107010103
• Wiyakorn Supapanyapong 54107010124
• Sasicha Yingyeunyong 54107010127
Case Information
• Case : 72-year-old Thai, Prachinburi-based
male
• Chief complaint : Progressive abdominal pain
for 1 day PTA
Present illness
3 weeks PTA, He had a severe tenesmus
after he ate 8 pieces of Kanom-Tein in the
morning. He went to Ban Sang hospital for an
enema administration
After the procedure was done, he passed a
plenty of normal stool but the pain did not
relieve. Then he was referred to Aphaiphubeth
hospital for admission and had been there for 15
days, the symptoms improved and he was
discharged.
Case Information (cont.)
Case Information (cont.)
1 day PTA, He complained of a sudden-
onset of intermittent abdominal pain, it took
about 5-10 seconds to a pain-free period. The
pain did not related to any meal or activity.
On that day he passed stool for 3 times, no
blood clot or mucous was seen but he noticed
that the stool caliber was smaller than before.
He also had history of anorexic symptoms,
nausea, vomiting, mild constipation and his
body weight decreased from 71 to 66
kilograms within 3 weeks.
Case Information (cont.)
Past history
–Underlying disease
• BPH
• Hypertension
• DM (Follow up at Bansang hospital,
baseline FBS 140-150 mg%)
• DLP (good control)
• Pterygium both eyes
Past history (cont.)
–Current medication : underlying disease
medication
–Surgical history
• S/P appendectomy 40 years PTA
–No accidental history
–No history of drug or food allergy
Past history (cont.)
–Alcohol drinking 1-2 glasses per day for 30
years
–No smoking
–No history of using herbs, boluses, decoctums
– Family history : his father had lung cancer
(dead)
Past history (cont.)
–Hospital admission history :
• 11-19 August 2014 at Aphaiphubeth hospital
Dx : Gut obstruction with pancreatitis
• 22 August 2014 at Aphaiphubeth hospital
ultrasound abdomen and acute abdomen
series : normal
Physical examination
• Vital signs :
–BT 38.0°C
–BP 138/77 mmHg
–RR 20 /min
–PR 90 bpm
• General appearance : A Thai old male, good
consciousness, not pale, no jaundice
• HEENT : moderately pale conjunctiva, dirty
sclera
• CVS : normal S1S2, no murmur
Physical examination (cont.)
Physical examination
• RS : normal breath sound
• Abdomen : mild distention, surgical
scar at RLQ, hyperactive bowel
sound, soft, generalized tender, no
rebound tenderness, no guarding
• Extremities: no pitting edema
• Per rectal examination: yellow feces, normal
sphincter tone, no feces impact
Physical examination (cont.)
Positive findings
• Sudden-onset of intermittent abdominal pain
with pain-free period
• History of severe tenesmus
• Abnormal stool passing with decreased stool
caliber
• Anorexia with significant weight loss
• Nausea and vomiting
Problem lists
• Generalized abdominal pain with decreased
stool caliber 1 day PTA
• History of tenesmus with loss of appetite and
significant weight loss 3 weeks PTA
Differential diagnosis
• Large bowel obstruction
• Small bowel obstruction
Provisional diagnosis
• Partial gut obstruction
LABORATORY
INVESTIGATION
Complete Blood Count (1/9/57)
• Hb 9.8 g/dL
• Hct 30.4 %
• WBC count 12,160 cells/mm³
–Neutrophil 80.1 %
–Lymphocyte 10.2 %
• Platelet count 597,000 cells/mm³
Blood chemistry (1/9/57)
• Na 132 mEq
• K 4.32 mEq
• Cl 97.2 mEq
• HCO3 22.6 mEq
• BUN 18.4 mg/dL
• Cr 0.93 mg/dL
Coagulation (1/9/57)
• PT 14.8 sec
• PTT 28.4 sec
• INR 1.25
Urinalysis (1/9/57)
• Yelllow, clear
• Sp.Gr 1.015
• pH 5.0
• Leukocyte neg
• Nitrite neg
• Protein trace
• Glucose 1+
• Ketone neg
• Urobilinogen neg
• Bilirubin neg
• Erythrocyte trace
• WBC 0-1/HPF
• RBC 0-1/HPF
• Epithelial cell 0-1/HPF
FILM ACUTE ABDOMEN SERIES SEPTEMBER 1ST ,2014
Findings
• Film chest X-Ray AP upright
–No free air under dome of diaphragm
–No infiltration or effusion both lung fields.
Findings
• Film abdomen supine
–Markedly dilatation of large bowel
–No air in rectum was seen
–Liver and spleen can not be evaluated
–Normal psoas muscle shadow both sides
–No widening paracolic gutter
–Normal bony structure
Findings (cont.)
Findings
• Film abdomen upright
–Markedly dilatation of large bowel with
air-fluid level was seen as “Different
height in the same loop”
–Liver and spleen can not be evaluated
–No free air under dome of diaphragm
–Normal psoas muscle shadow both sides
–No widening paracolic gutter
–Normal bony structure
Findings (cont.)
FILM ABDOMEN SUPINE SEPTEMBER 2ND ,2014
Findings
• Film abdomen supine
–Markedly dilatation of ascending,
transverse and descending colon
–No air in rectum was seen
–Liver and spleen can not be evaluated
–Normal psoas muscle shadow both sides
–No widening paracolic gutter
–Normal bony structure
Findings (cont.)
FILM ABDOMEN UPRIGHT SEPTEMBER 2ND ,2014
Findings
• Film abdomen upright
–Markedly dilatation of large bowel with
air-fluid level was seen as “Different
height in the same loop”
–Liver and spleen can not be evaluated
–No free air under dome of diaphragm
–Psoas muscle shadows were not seen
–No widening paracolic gutter
–Normal bony structure
Findings (cont.)
CT SCAN WHOLE ABDOMEN
WITH CONTRAST
(CORONAL VIEW) SEPTEMBER 2ND ,2014
Findings
• Markedly dilatation of ascending, transverse
and proximal part of descending colon
• Thickening wall of distal part of descending
colon at L4 paravertebral level measured 55.14
mm in length
CT SCAN WHOLE ABDOMEN
WITH CONTRAST
(AXIAL VIEW) SEPTEMBER 2ND ,2014
Findings
• Markedly dilatation of ascending, transverse
and proximal part of descending colon
• Thickening wall of distal part of descending
colon measured 20.2 mm in width
Conclusion
• A 72-year-old Thai male with CC of
abdominal pain for 1 day PTA. Plain film in
acute abdomen series shows and “Different
height in the same loop”. CT scan shows
thickening wall of distal part of descending
colon.
• Diagnosis : Large bowel obstruction due to
colonic mass
Treatment
Principles of treatment:
–En bloc resection
–Additional treatment
• Chemotherapy : stage III
–5 Fluorouracil and Leucovorin
–Oxaliplatin (NCCN recommended)
Treatment
–Follow up : 1-2 years
• First 2 years : Follow up every 3 months
• 2-5 years : Follow up every 6 months
• After 5 years : Follow up annually
KNOWLEDGE
CT scan
• Diagnosing and staging colorectal carcinoma
–Accuracy 45-77% asses nodes and metastases
– Insensitive to small masses
• Findings
–Soft tissue density, ulceration, narrow lumen
–Occasionally low-density masses and
calcifications in mucinous adenocarcinoma
• Complications may also be evident
MRI
• Accuracy 73% and sensitivity 40% for lymph
node metastases
• MR is having an increasing role to play in the
staging of rectal cancer.
Barium enema
• Sensitivities for polyps >1 cm
–Single contrast: 77-94%
–Double contrast: 82-98%
• Polyps <1 cm: < 50% detection
• Findings:
–Macroscopic appearance as filling defects.
–Exophytic, sessile, circumferential masses
–Fistulas may also be demonstrated.
Apple-core lesion
• The appearance of the apple-core lesion of the
colon also can be caused by other diseases
• Differential diagnosis
– Lymphoma
– Crohn’s disease
– Chronic ulcerative
colitis
– Ischaemic colitis
– Chlamydia infection
– Colonic tuberculosis
– Helminthoma
– Colonic amoebiasis
– Colonic
cytomegalovirus
– Villous adenoma
Take home message
• Signs of gut obstruction in plain film
–Markedly bowel dilatation of the proximal
portion of obstruction
• Small bowel > 2.5 cm in diameter
• Large bowel > 5 cm in diameter
– “Stepladder pattern” of small bowel in
supine position
Take home message
–Disproportion of air between small bowel
and large bowel
– “Different height in the same loop” of air-
fluid level in upright position
– In chronic case, the “string of beads” may
presents in upright position