Grand Rounds Case Study Neil Bedi, Sina Shahrzad, Pieter Cory HBS Neil

The Patient Dominic Aldridge Gender: Male Age: 46 Year Old Height: 71 Inches Weight: 153.3 lbs Heart Rate: 70 bpm Blood Pressure: 140/87 Sina

Original Symptoms Dominic said he’s been feeling these symptoms for a while: Some pain in the lower abdomen/back Had a very low fever, on and off, for the past two weeks Discoloration in his left leg Has had to urinate a lot more often than normal Has difficulty urinating at times Has vomited twice in the past five days Pieter

Signalment Question: How long have you felt your symptoms? Answer: I felt them for a while, but the symptoms started getting bothersome about two weeks ago. Question: Did you have any past conditions that could link to these symptoms? Answer: No, I have never felt these types of symptoms before. Question: Did you have any genetic history that could link to these symptoms? Answer: No, and I don’t know if this is relevant, but high cholesterol generally runs in my family. Question: Are you on any medications? Answer: Not really, I just take my daily vitamin supplements every morning. Sina

Primary Differential Diagnosis (DDx) Nephrolithiasis Bowel obstruction Spinal Cord Compression Peripheral Edema Peripheral Thrombosis Retroperitoneal Fibrosis Hydrocele Peritonitis Neil does first three, Pieter does second three, Sina does last three

Suggested Labs and Tests CBC (Complete Blood Count Test) measures several components and features of your blood Chemistry Panel Complete analysis of the compounds in the blood Urinalysis An analysis of the urine output of a patient Pieter

CBC Results The CBC showed normal hemoglobin content of the red blood cells. But size and shapes of the red blood cells varied. These variations balanced out the average, yielding the normal levels we evaluated. This is called Normocytic normochromic anemia. Sina

Chemistry Panel Results The results from the Chemistry Panel: Elevated CRP levels (C-Reactive Protein) Elevated Creatinine levels Elevated BUN levels (Blood Urea Nitrogen) Elevated ESR levels (Erythrocyte Sedimentation Rate) Elevated Alkaline Phosphatase levels Elevated IgG4 levels Neil does all but Sina does IgG4

Urinalysis Results The results from the Urinalysis: Normal Slight microscopic hematuria Sina

What do we know now? Symptoms are likely being caused by some sort of injury or disease to the kidney, ureter, or bladder Possible problem in the liver (could be caused by patient diet) Next Steps: CT Scan Kidney Ultrasound If a mass is present: a Needle Biopsy Neil

Scan Results Pieter http://www.radiologycases.com/index.php/radiologycases/article/viewArticle/722

Biopsy Results The results of the biopsy: The cells extracted showed the presence of: Fibrous tissue Inflammatory cells With this we can make our diagnosis We found the mass behind Dominic’s abdominal lining to be benign (not malignant) Benign: A tumor or mass that does not invade surrounding tissue or spread to other parts of the body; it is not a cancer Malignant: A tumor or mass that can invade and destroy nearby tissue and that may spread to other parts of the body. Sina

Retroperitoneal Fibrosis Diagnosis Retroperitoneal Fibrosis *RPF = Retroperitoneal Fibrosis Neil

Possible Treatments Corticosteroids Creates anti-inflammatory action and the ability to inhibit fibrotic tissue formation Tamoxifen Increases the secretion and synthesis of transforming growth factor, which is an inhibitory growth factor Open Ureterolysis The relief of pressure off the ureters through an open surgery Laparoscopic Ureterolysis The minimally invasive procedure of relieving pressure from ureter Pieter does the first 2, Neil does last 2

Plan Laparoscopic Ureterolysis to remove pressure from the ureters and reduce the risk of Renal Failure, and to reduce pressure off of the spinal cord and the ureters Neil

Laparoscopic Ureterolysis Video Neil https://www.youtube.com/watch?v=SUnIvEjH6Pg

Prognosis/Future Care Post-Op Care Dominic should begin to check in with us for a CT scan quarterly to make sure that the RPF has been treated well He can begin to come in semi-annually when we are sure that there is a low possibility of a remission Dominic should also be careful with his diet and begin to generally eat healthier foods Due to his high cholesterol (high LDL), Dominic needs to consume foods lower in fat and cholesterol We found that some RPF cases have been linked to atherosclerosis, so we want to ensure Dominic’s good health by regulating his diet Neil does first bullet, Pieter does second bullet, Sina does third bullet

Our Innovative Treatment for RPF Retroperitoneal fibrosis is a condition where one has a mass buildup of inflammatory cells on the retroperitoneum (anterior lining of the abdomen). There are anti-inflammatory medicines that are being researched right now that are more advanced than NSAIDs (aspirin, ibuprofen, etc.) These anti-inflammatories attack the inflammatory cells and kill them The medicine is taken through injection instead of orally This could be a developing and innovative treatment for RPF Sina

References (CSE Format) Biyani , Schwartz . Evaluation of Acute Abdominal Pain in Adults [Internet]. Available from: http://emedicine.medscape.com/article/458501-overview Cartwright . 2008 Apr 1. Evaluation of Acute Abdominal Pain in Adults [Internet]. Winston-Salem(NC): . Available from: http://www.aafp.org/afp/2008/0401/p971.html Connealy . 2012 Aug 20. Blood Test Results: Your Guide to Understanding the Numbers [Internet]. ; [2015 Mar 6] . Available from: http://www.newportnaturalhealth.com/2012/08/a-guide-to-understanding-blood-tests/ Giorgi AG. 2016 Jan 5. Retroperitoneal Fibrosis [Internet]. Available from: http://www.healthline.com/health/retroperitoneal-fibrosis Mufarrij , Stifelman . 2006 August. Robotic Ureterolysis, Retroperitoneal Biopsy, and Omental Wrap for the Treatment of Ureteral Obstruction Due to Idiopathic Retroperitoneal Fibrosis [Internet]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1751033/ Pieter

References (CSE Format) Scheel . Retroperitoneal Fibrosis [Internet]. Baltimore (MD):. Available from: http://www.hopkinsmedicine.org/nephrology/retroperitoneal_fibrosis.html Shiber , Raz . 2016 March. Retroperitoneal fibrosis: case series of five patients and review of the literature [Internet]. Available from: http://www.sciencedirect.com/science/article/pii/S2255502114002065

Thank You! Neil