Right Lower Quadrent Pain And Mass

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Right Lower Quadrent Pain And Mass

• Presented by 1. Ali d. al-ghamdi.
• 2. Dhafer a. al-shahrani.
• 3. Ibrahim Qaisi.

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Right Lower Quadrent Pain And Mass
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Acute RLQ pain
Chronic RLQ pain
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Right Iliac Fossa Swelling
Small bowel
Ascending colon
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Groin Swelling
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Work up of Abdominal Pain

• History History
• Onset
• Qualititive description
• Intensity.
• Frequency.
• Location (Does it go anywhere? Referred?
• Duration ?
• Aggravating and Alleviating Factors

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Laboratory Tests Urine analysis Urine
Pregnancy CBC Chem, LFT, - depending on
differential
Physical Examination Physical Examination
Inspection Palpation ,Percussion rebound
tenderness Guarding - Auscultation Rectal
Exam Pelvic Exam
Diagnostic studies Plain Films Ultrasound
Ct Scan
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Acute appendicitis
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Clinical Aresentation of Appendicitis
-          Symptoms o         Classical
presentation is of a central Colicky abdominal
pain which localises to McBurney's point. The
central abdominal pain, is visceral and midgut in
origin (hence the umbilicus), and the
localisation is caused by local peritoneal
irritation in the RIF  o         Associated
symptoms Nausea, vomiting, anorexia. -In infants
diarrhoea vomiting may be the only symptoms.

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YET NOT ALWAYS SO CLASSIC
- 40 of patients present atypically. - Atypical
presentation more likely if extremes of age,
pregnant immunocompromised, or atypical
anatomical location of appendix.
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O/E

• o        General
•   tachycardia
•   Fever (low grade)
• o         Abdomen     
•   -Tenderness and guarding at McBurneys point
  the junction of the middle and outer thirds of a
  line which joins the umbilicus to the ASIS
•   -Rovsings Sign Pressure applied in LIF causes
  increased pain in the RIF
•    -Rebound tenderness

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Investigations

• Diagnosed clinically (usually)
• WBC elevated
• X-ray if ureteric colic is suspected
• US for females to role out ovarian pathology

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Treatment Complication

• appendectomy with prophylactic metronidazole by
  suppository should be given 1hour preoperatively
  to reduce the risk of wound infection.
• - Complication
• 1- appendicular mass
• Omentum small bowel adhere to inflamed appendix
  
• Rx conservative ( IV fluid , analgesics ,
  cefuroxime , metronidazole )
• if the mass resolved carry out an interval
  appendectomy after 3 months
• if it gets bigger , it is likely that an
  appendicular abscess has formed
• 2- appendicular abscess
• CT to diagnose it
• Rx drainage and appendectomy or percutaneous
  drainage under US or CT control
  interval appendectomy is required subsequently .

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Meckels diverticulum

• The rule of 2's
• -    occur in 2 of the population
• - symptomatic in 2 of cases
• -    2 feet from the ileocaecal valve (60cm)
• -    2 inches in length (5 cm)
• -    21, malesfemales
• -    2 types of mucosa, gastric and intestinal(or
  pancreaatic).
• - 2 presentations ( bleeding obstruction )

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Clinical feature

• Vary greatly and may be noted as an incidental
  finding. However the Meckels may present with
• -     Acute diverticulitis   mimic appx
• -     Intussusception
• -     Small bowel obstruction
• -     Perforation
• -     'Gastric' ulcer type picture (ectopic
  peptic ulcer on mesentric border of adjacent
  ileum), due to the presence of gastric mucosa
  cells Abdo pain and small-bowel bleeding .
• - Confirmation of Dx
• 99m Tc sodium pertechnetate.

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Management

• Asymptomatic Incidental finding
• - if in Children - Generally removed as a
  precaution
• - if in Adults - Generally left in situ.
• Symptomatic Acute diverticula
• - Treat as in diverticulitis according to
  complication they cause.

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Crohns disease
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Epidemiology
Crohns disease (CD) is a chronic relapsing
inflammatory condition usually with flare-ups
alternating with periods of remission, and an
increasing disease severity and incidence of
complications as time goes on. It can affect
any part of the gastrointestinal tract from the
mouth to the anus. For typical sites
proportion of patients affected see below
Terminal Ileum only 20
Extensive Small Bowel 5
Ileocaecal 45
Colon only 25
Other anorectal, gastroduodenual, oral only 5
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• - The incidence is lower in non-white races.
• - The incidence is rising.
• - Bimodal age distribution20-40 yrs/60-80 yrs
• - Females are affected more than males 1.21

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Pathology
It is characterised by patchy transmural
inflammation. There is an increased permeability
in gut epithelium which allows antigens into the
tissues. The chronic inflammatory process leads
of thickening of the bowel wall and can cause a
narrowed lumen. In early CD there are prominent
lymphoid follicles followed by aphthoid
ulceration. Later this progresses to larger deep
fissuring ulcers separated by normal looking
mucosa (cobble-stoning), fibrosis, stricturing
and fistulation. These changes are often
segmentally distributed (skip lesions).
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Some of the complications of CD are outlined
below Fistula formation abnormal channels of
communication can form in CD between loops of
bowel, bladder and skin. If the CD is in the
colon, fistulae can form between the colon and
vagina or between the colon and perineum.
The diagram on the right shows the beginning of a
fistula formation with a fissure extending though
mucosa towards the muscular wall. Below is a
representation of a fistula starting from an area
of ulceration
Obstruction - typically occurs from strictures or
adhesions which narrow the lumen, blocking the
passage of the intestinal contents. This can be
seen in the barium follow-through to the right.
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Aetiology Pathogenesis
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Clinical Features
The clinical presentation can be very variable
depending upon the site and predominant pathology
of that site. Major symptoms include Diarrhoea
(can be bloody with colonic involvement, or
steatorrhoea in small bowel disease) Abdominal
pain Weight loss Constitutional symptoms such as
malaise, anorexia, nausea, vomiting and a low
grade fever. To make things more complicated
15 of patients have no gastrointestinal symptoms
at all! CD here can sometimes present as an
emergency with acute right iliac fossa pain which
mimics appendicitis. Cohn's colitis Similar to
ulcerative colitis but less blood in the
diarrhoea. Extra-intestinal features are more
common in CD of the colon crohns colitis than
CD of the small bowel.
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Intestinal Complications
Anal and perianal complications Fissure in ano or
fistula in ano Haemorrhoids Skin tags Perianal or
ischiorectal abscess Anorectal fistulae Cancer Wi
th Crohns colitis, there is a increased risk of
colorectal carcinoma There is an small increased
risk of rarer small intestinal and anal cancers
occurring in cites of prolonged inflammation.
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Extra-intestinal complications
There are many systemic associations and
complications of CD, most affecting the liver and
biliary tree, joints, skin and eyes
Sclerosing Cholangitis occurs in a small
proportion of patients. The pathogenesis is
unknown and the condition is characterised by an
inflammatory obliterative fibrosis of the biliary
tree (the white in the diagram-gt). It progresses
slowly and a liver transplant is the only cure.
Ankylosing spondylitis affects about 5 of
patients with Crohns colitis. The patient
presents with back pain and stiffness and the
diagnosis can come years before the CD.
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Extra-intestinal complications
Erythema nodosum occurs in 8 of Crohns
colitis patients when disease is active. Hot, red
tender nodules appear on the arms and legs and
subside after a few days.
Pyoderma gangrenosum occurs in 2 of CD
patients, starting as a small pustule, then
developing into a painful, enlarging ulcer, most
commonly on the leg.
In addition to these conditions, other
complications and associations include
episcleritis and uveitis (occuring in 5 of
patients with active disease), osteoporosis (as a
consequence of chronic inflammation, malabsortion
and treatment with corticosteroids) and
arthropathy.
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Diagnosis and Management
Radiology and imaging
Barium follow-through findings consistent with
Crohns include an asymmetrical alteration in
mucosal pattern with deep ulceration and areas of
narrowing or stricturing.
Colonoscopy, terminal ileoscopy biopsy These
allow direct visualisation and allows for a
biopsy of the mucosa to be taken. This is
central to macroscopic and microscopic diagnosis.
Ultrasound CT scanning Can help define
thickness of the bowel and mesentery and can be
useful to evaluate disease progress chart
fistula formation.
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Blood tests Haematology results suggesting
anaemia, ? platelet count ? ESR suggests an
inflammatory bowel condition. Biochemistry ?
C-reactive protein and ? serum albumin suggests
active CD. Liver biochemistry may be
abnormal. Stool cultures Faecal calprotectin
provides accurate marker of inflammatory
activity. Calprotectin is a neutrophil-derived
cytosolic protein that is resistant to bacterial
degradation and if present in the stools provides
an accurate index of intestinal inflammatory
activity. It is not routinely available but has
the potential to be a simple, cheap, non-invasive
marker. Stool cultures should be done to rule
out infection as a differential diagnosis.
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Management
Treatment depends upon the disease activity and
site but should also be tailored to the clinical
presentation and underlying pathology. The aim
in to induce and maintain remission. Risk
factors outlined earlier (such as smoking)
should be avoided Diarrhoea can be controlled
by anti-diarrhoeals. The drugs most commonly
used to induce remission are aminosalicalates,
corticosteroids (oral), Infliximab and
Methotrexate. Surgery is indicated for
perforation or haemorrhage (emergency) or for
small-bowel obstruction, Crohn's colitis, abscess
(intra-abdo and perianal), fistulas and
inflammation unresponsive to medical
therapy. Approximately 80 of patients with CD
will require surgery at some point. Surgery is
not curative. The surgery most applicable for
small bowel CD is resection end-to-end
anastomosis whereas for colonic involvement the
most suitable surgical options are segmental or
subtotal colectomy.
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summary of crohns dis.

• The clinical presentation and subsequent
  treatments depend upon the site of inflammation
  and the type of pathology underlying it. For
  example, the most common site is the ileocaecal
  area which presents typically with pain and/or
  tender mass in right iliac fossa with or without
  diarrhoea and weight loss. On the other hand oral
  CD presents with mouth ulcers and induration.
• Recurrence
• The rate is high either early or late .
• 40 within 5 years
• 60 within 10 years
• 75 within 15 years

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Carcinoma of caecum and right colon
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Epidemiology

• Colon(rectum) cancer is the 3rd most common
  cancer after breast and lung.
• FgtM
• Pathophysiology majority
• are adenocarcinoma
• Pathological features
• -          Site
• o        Rectum 57
• o        Sigmoid 21
• o        Caecum 6
• o        Trans Colon 5
• o        Asc colon 3
• o        Splenic flexure 3
• o        Hep flexure 2
• -          Synchronous lesions
• o        Up to 3 of patients have one or more
  synchronous cancers

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Risk factor
6-          Genetic factors o        FAP
o        Hereditary non-polyposis colon cancer
(HNPCC) accounts for about 10 of colon
malignancies. 2-3x increased risk if first
degree relative with adenocarcinoma o       
1/10 Ashkenazi Jews carrying a fault
gene. 7-          IBD o        UC o       
Crohns 4x risk of CRC

• 1-          Age 80 diagnosed after 60 years of
  age
• 2-          Previous history of CRC
• 3-          Dietary factors
• o        Bile salt conversion A suggested theory
  of diets being high in bile salts leading to
  conversion by bacteria to carcinogens
• o        Reduced intake of fibre Slows transit
  increasing the time of exposure of the mucosa to
  carcinogens
• 4-          Adenomatous polyps
• 5-          Family history

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• Symptoms associated with colon ca
• -          Change in bowel habit
• -          PR bleed(occult in feces) and/or mucus
  
• -          Abdominal pain
• -          Malaise
• -          Weight loss
• -          Anaemia
• -          Tenesmus
• o        specific to Right sided tumours (in
  relation to left)
•           Non specific complaints
•           Malaise
•           Weight loss
•           Non-specific abdominal pain(late dull
  ache)
•           ?Mass in abdomen
•           ?Iron deficiency anaemia
• . Acute appx if tumour block the mouth of
  the appx causing it to dilate.

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• On examination
• -          Usually unremarkable
• -   general appearance pale thin.
• - tenderness in RIF
• - irregular mass.
• - dull in percussion.
• -normal bowl sound unless obstruction or
  peritonitis.

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Investigation

• - Stool ve for occult blood.
• - Blood film iron def. anaemia.
• - Barium enema apple core lesion or
• Constrictions or intraluminal mass.
• - Colonoscopy
• o  Investigation of choice
• oDirect observation of whole colon
• -  Tumour marker
• o        CEA carcinoembryonic antigenshould be
  used as marker for elimination or recurrence and
  not in the diagnosis raised
• - ESR raised

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Staging

• -          Duke Stage A Confined to mucosa
• o        90 5 year survival
• -          Duke Stage B Extended through muscle
  layers and possibly reached serosa
• o        60 5 year survival
• -          Duke Stage C B lymph node mets
• o        30 5 year survival
• -          Duke Stage D Disseminated metastatic
  disease
• o       less than 5 5yrs survival.

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Management

• o        Rx of Dukes A to C disease is primarily
  by surgical removal, and this is accompanied in B
  and C by adjuvant therapy.
•           Right-sided tumours Right
  hemi-colectomy.
• o        Advanced disease
• -          Local disease and recurrence
• o        When disease progression is extensive
  the cancer may be debulked using a combination of
  chemotherapy and radiotherapy in order to reduce
  symptoms .
• -          Hepatic mets
• o        Solitary hepatic mets may be suitable
  for resection

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After surgery
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