1. Intern Seminar
Reported by Richard

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

3. 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 (+)

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

5. 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

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

7. CT finding:

8. 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

9. 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.

10. 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.

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

12. 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

13. 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

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

15. LGIB
Apple core

16. CT -Lumen thickness+ LAP
Colon Ca
Ischemia colitis

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

18. CT -local extension and metastasis
Anterior wall extension
Liver metastasis

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

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

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

22. LGIB
Cobblestone sign
combination of transverse and longitudinalulcers

23. LGIB
String sign
Luminal narrowing + ileal stricture

24. CT
Double halo sign

25. CT
Comb sign
mesenteric hypervascularity

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

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

28. LGIB
Collar-button ulcer
Ulcer enlarge configuration loss

29. LGIB
Pseudopolyp
represent residual islands of uninvolved colonic mucosa

30. LGIB
Ahaustration
Flask-like

31. CT Bowel wall thickening Colorectal narrowing
Perirectal fibrofatty proliferation

32. 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

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

34. 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

35. Fluoroscopic guided barium study
Thumbprinting sign

36. CT
Bowel wall thickening
Bowel wall attenuation

37. Pneumatosis mesenteric vein gas portal vein gas

38. 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

39. CT
Wall thickness with spiculaing
Concentric wall thickness

40. CT
lymphadenitis

41. CT
inflammation extends into the psoas muscle

42. Thanks for your listening…