RLQ ABDOMINAL PAIN

Reshma B. Patel Scott Q. Nguyen, MD

Randolph Steinhagen, MDCelia M. Divino, MD

Department of SurgeryMount Sinai School of Medicine

New York, NY

Mr. X

A 25 year-old male presents with a 1 month history of nausea, intermittent vomiting right-sided abdominal pain, bloating, episodic diarrhea, fatigue, and weight loss.

History

What other information would be helpful?

History, Mr.XHistory, Mr.X

• Characterization of symptoms

• Temporal sequence• Alleviating /

Exacerbating factors:

• Pertinent PMH, ROS, MEDS.

• Relevant family hx.• Associated signs and

symptoms

Consider the Following

History• Pain:

• Quality: Cramping and right sided• Radiation: None• Severity: 5/10• Timing: Intermittent, coming in waves, and worse after eating.

• Nausea: • intermittent w/ occasional vomiting for past month. Feels

persistently bloated and distended. Appetite decreased. Hasn’t been able to eat much in past week.

• Diarrhea: • Episodic watery and non-bloody.

• Weight Loss:• 10 lbs over last month. Appetite decreased. Hasn’t been able to eat much in

past week.

History

• PMH: Patient states that he has had bouts of diarrhea for years and was previously diagnosed with irritable bowel syndrome.

• PSH: Laparoscopic Cholecystectomy 2000• Meds: None• Family Hx: Grandfather died from colon cancer• Social Hx: No tobacco, alcohol, or drug use.

Traveled to Mexico 2 months ago

Differential Diagnosis

• Irritable Bowel Syndrome• Partial Small Bowel Obstruction

• Appendicitis• Diverticulitis

• Infectious diarrhea (Salmonella,Shigella,Campylobacter, TB)• Parasitic infection (amebic infection)

• Celiac Sprue• Ulcerative Colitis• Crohn’s Disease

• Pseudomembranous Colitis • Intestinal Lymphoma

• GI Malignancy• Mesenteric Adenitis

Physical Exam

• Vitals-Temp: 39 C BP: 105/65 HR: 100 RR:15

• Gen: Thin appearing male.

• Cardiac: S1,S2. RRR. No murmurs, gallops, or rubs

• Lungs: CTAB. No wheezes, rales, or rhonchi

• Abdomen: Soft, somewhat distended, mildly tender to palpation worse in the right lower quadrant. Palpable mass in right lower quadrant. Bowel sounds hyperactive. No organomegaly. No guarding or rebound.

• Rectal: Sphincter tone normal. Perirectal erythema and tenderness. Anal fissure noted at 3 o’clock position. Heme positive.

• Musculoskeletal: Normal range of motion in all four extremities.

• Extremities: No erythema or edema.

Review of Systems

Non-contributory except for:

• Gen: fever, fatigue, and weakness x 1 month; 10 lb weight loss over last month

• GI: Decreased appetite with nausea for 1 month. Denies vomiting. Worsening watery, non-bloody diarrhea for 1 month.

Laboratory

What tests should you order?

More importantly………why?

Labs

• CBC

• Chem 7

• UA: Wnl• FOBT: Positive• Stool O & P: Negative

11

11

35

400

135

3.4

110

23

30

1.0104

Labs: Significance?

• Mild Leukocytosis : ? inflammatory process• Electrolytes: hypokalemia, elevated

bun/creatinine volume depletion and potassium loss

• Anemia and +fobt: blood loss

What’s the differential diagnosis?

Differential Diagnosis• Irritable Bowel Syndrome

• Appendicitis

• Diverticulitis

• Partial Small Bowel Obstruction

• Infectious diarrhea (Salmonella,Shigella,Campylobacter, TB)

• Parasitic infection (amebic infection)

• Celiac Sprue

• Ulcerative Colitis

• Crohn’s Disease

• Pseudomembranous Colitis

• Intestinal Lymphoma

• GI Malignancy

• Mesenteric Adenitis

Acute Management/Interventions

• Hydration / Fluid resuscitation

• Correct electrolyte imbalances

Imaging:Obstructive Series

Imaging: Obstructive Series

Imaging: Obstructive Series

Your interpretation?

Imaging: Obstructive Series• No free air under the diaphragm

• Few dilated loops of small bowel with air fluid levels in the Left abdomen

• Some air noted in colon

• Consistent with partial small bowel obstruction

What test next?

Imaging: Small Bowel Series

Small bowel series: Interpretation

Narrowing of the terminal ileum with multiple strictures. Mass at RLQ pushing remaining

small bowel aside.

Colonoscopy

• Colonic mucosa normal appearing• Difficultly traversing the ileocecal valve• Terminal ileum beefy and red with linear

ulcerations adjacent to normal appearing mucosa with a cobblestone appearance

• Biopsies taken

Biopsy Results

• Inflammation with neutrophilic infiltration into epithelial layer and accumulation into crypts forming crypt abscesses

• Scattered lymphoid aggregates throughout the tissue layers

• Non-caseating granulomas• Ulceration • Chronic mucosal damage with architectural distortion

and atrophy

What’s the Diagnosis?

Crohn’s Disease• The first line treatment for Crohn’s Disease is medical

therapy

Asymptomatic or Minimally Symptomatic Disease:• 5-ASA compounds (sulfasalzine, mesalamine): topically affects bowel

in reducing inflammation• Antibiotics: ciprofloxacin and metronidazoleModerate to Severe Disease• Corticosteroids: potent anti-inflammatory agent for refractory cases and

acute flares• Immunomodulators: (azathioprine, methotrexate, infliximab) modulate

immune system / immune cells active in inflammatory response

When is surgical intervention warranted?

Surgical Indications

• Stricture• Fistula• Abscess• Carcinoma• Failed medical therapy

Crohn’s Disease

Creeping fat onto antimesenteric border of inflammed, thickened small bowel

Specimen

Surgical Technique

• Creeping fat

Crohn’s Features

Cobblestoning

Inflammatory Bowel Disease• Crohn’s disease and ulcerative colitis• Chronic inflammatory disease of the gastrointestinal tract• Incidence and prevalence vary with geographic location; more

common within Jewish population• Higher rates for whites in northern Europe and North America• Incidence for each is 5 per 100,000• Prevalence for each is 50 per 100,000• Incidence equal in men and women• Bimodal age distribution: peak age onset between15-25yrs;

second peak 55-65yrs old

Crohn’s Disease: Etiology & Pathogenesis

• Family history key risk factor• Infiltration of lamina propria by lymphocytes,

macrophages, and other inflammatory cells• Inability to down regulate chronic inflammation of

lamina propria triggered by exposure to antigens• Epithelial injury due to reactive oxygen species

and cytokines

Crohn’s Disease Ulcerative ColitisTransmural involvement Mucosal Disease

Segmental “skip lesions” Diffuse involvement of entire colon

Rectal involvement rare Rectum always involved

Thickened bowel wall with “creeping fat”

Normal bowel all thickness

Small bowel commonly effected Small bowel not effected except with backwash ileitis

Cobblestoning Pseudopolyps

Narrow, deeply penetrating ulcers Shallow, wide ulcers

Granulomas common Granulomas rare

Crohn’s Disease: Extraintestinal Manifestations

• Apthous ulcers • Cholelithiasis• Arthritis• Skin lesions: erythema nodosum, pyoderma

gangrenosum• Ocular lesions: episcleritis, uveitis

References• ACS Surgery Principles and Practice

• Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 8th edition 2006.

• Goldman:Cecil’s Textbook of Medicine. 22nd edition 2004.

• Kumar et. al. Robbin’s Basic Pathology. 7th edition 2003

• Lawrence, P. Essentials of General Surgery. 3rd edition 2000.

• Townsend: Sabiston Textbook of Surgery. 17th edition 2004.

• Zimmer, M. Maingot’s Abdominal Operations. 11th edition, 2004.

• **Pictures courtesy of Dr. R. Steinhagen

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