Intern Seminar Reported by Richard

Identification 17 year old male Name: 宋X志 Chart No.: 11660829 Chief complain: Severe abdominal distension for 3 days

Present illness: Severe abdominal fullness with for 3 days followed by abdominal pain on the admission day. He went to Local clinic then transferred to our ER. Nausea(+), Anorexia (+), Constipation (+), Fever(+), Small caliber stool (+)

Physical examination: Vital sign: T: 38.0℃; P:110/min; R: 20/min ; BP:128/81 mmHg Abdomen: Diffuse distention(+) Tenderness (-) Rebound Pain (-)

Lab data: WBC 5100/cmm GOT 22 U/L Hb 12.9 g/dl GPT 35 U/L MCV 80.2 fl Bi-T 0.8 mg/dl Platelet 404K/cmm Bil-D 0.1 mg/dl Glucose 125 mg/dl Na 129 mmol/L Amylase <30 U/L K 3.4 mmol/L Lipase <10 U/L Cl 93 mmol/L Creatinine Albumin 4.1 g/dL BUN 9 mg/dl CRP 87.3 mg/L

Image finding: KUB: Ileus NG decompression NPO IVF D5W 80ml/hr Cefoxitin 1vial q6h

CT finding:

Impression: Bowel obstruction ileus Infections disease TB, Pseudomembrane colitis Inflammatory bowel disease Crohn’s disease, ulcerative colitis Tumor Malignant: Colorectal cancer, Lymphoma, meta Benign: Lipoma Ischemic bowel Trauma Volvulus Hernia Stone, Bezoars

Surgical intervention: Very dilated small bowel and colon caused by S-colon tumore with total obstruction. Tumor size is about 5sm in size. The tumore is ulcontive, seems involve with serosa, regional LNs enlargement(+), IMA root LNs enlargement(+) Detotoriated ischemic chang; terminal ileum ischemic change below 180 cm to 370 cm from Traitz ligment was noted and could not be recoverred under pure pad packing; segmental resction of small bowel with end to end anastomosis; But then some ischemic change since the site distal to anastomosis to IC valve was noted and could not be recoverredl Then we perferral subtotal colestectomy with resection of small bowel. Left 180cm, and resect: 265 cm. little stool leakage to peritoneum with large amount N/S irrigation.

Pathological finding: The colon shows a picture of moderately differentiated adenocarcinoma with invasion through the whole layer to the pericolic soft tissue. 8 of 44 regional lymph nodes reveal metastatic lesions. Bilateral section margins are free. Acute and chronic inflammation cells infiltration and fibrinous exudate coating on the omentum is seen, compatible with peritonitis. No metastatic tumor cells is seen. The resected bowel shows diffused ischemic change with venous congestion and mucosal erosion. No tumor thrombi is seen in the vessels.

Discussion Colonic Obstruction In Young Age By intern盧佳文 2006/09/27

Colonic Obstruction Intrinsic Extrinsic Luminal obstruction Intussusception Fecal impaction Bowel wall lesion Malignant Colon Ca Inflammation Crohn disease Ulcerative colitis Mesenteric ischemia Diverticulitis Infection TB Extrinsic Mass compression Large tumor mass: prostate, bladder, uterus, tubes, ovaries Endometriosis Pelvic abscess Severe constriction Volvulus Hernia adhesion

Colon Ca Epidemiology Clinical presentation Incidence: 32.9/100000 Age: age↑, incidence ↑ <30 y/o:11%-13% Gender: M:F=3:2 Clinical presentation Rectosigmoid: small caliber stool, tenesmus Left-side colon: bowel obstruction Right-side colon: chronic bleeding, IDA

Location Cecum:10% Ascending colon:15% Transverse colon:15% Descending colon:5% Sigmoid-rectum:55%

LGIB Apple core

CT -Lumen thickness+ LAP Colon Ca Ischemia colitis

CT -Bowel wall attenuation due to necrosis Colon Ca Ischemia colitis

CT -local extension and metastasis Anterior wall extension Liver metastasis

Crohn Disease Epidemiology Clinical presentation Incidence:0.08/100000 Age: 15-25 years old (small peak at 50-80y/o) Gender: M=F Clinical presentation Diarrhea Abdominal pain, chronic&recurrent Melena, weight loss, fever…

Image findings Location Terminal ileus: 95% Colon: 22-55% Rectum: 14-50%

LGIB -Aphthoid ulceration (target or bull’s eye appearance)

LGIB Cobblestone sign combination of transverse and longitudinalulcers

LGIB String sign Luminal narrowing + ileal stricture

CT Double halo sign

CT Comb sign mesenteric hypervascularity

Ulcerative Colitis Epidemiology Clinical presentation Incidence: 0.5/100000 Age: 15-25 y/o (small peak at 55-65 y/o) Gender: M:F= 1.8:1 Clinical presentation Bloody mucus diarrhea abdominal pain and cramping Tenesmus, rectal bleeding…

Image findings Location Rectum: 30% Rectum+colon: 40% Pancolitis: 30%

LGIB Collar-button ulcer Ulcer enlarge configuration loss

LGIB Pseudopolyp represent residual islands of uninvolved colonic mucosa

LGIB Ahaustration Flask-like

CT Bowel wall thickening Colorectal narrowing Perirectal fibrofatty proliferation

CD &UC CD UC Distribution Skip lesion Terminal ileus, Colon, Rectum Continuous lesion Rectum,colon Involvement Transmural Mucosa and submucosa Radiology Bull’s eye, cobblestone, string sign,comb sign Collar-button sign, lead-pipe colon and ahaustration CRC risk No Yes

Ischemia colitis Epidemiology Clinical presentation Age: >50 y/o Gender: M=F Clinical presentation Abdominal pain Rectal bleeding, bloody diarrhea, hypotension

Image findings Location: watershed segment Splenic flexure: junction of AMA&IMA Recto-sigmoid: junction of IMA&hypogastric a. Right side colon: young age Left side colon: old age

Fluoroscopic guided barium study Thumbprinting sign

CT Bowel wall thickening Bowel wall attenuation

Pneumatosis mesenteric vein gas portal vein gas

TB Epidemiology Clinical presentation Location Age: any age, child and old age predominant Gender: M>F Clinical presentation abdominal pain weight loss, fever and night sweats Location peritonium, GI tract, liver

CT Wall thickness with spiculaing Concentric wall thickness

CT lymphadenitis

CT inflammation extends into the psoas muscle

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