RLQ ABDOMINAL PAIN
Reshma B. Patel
Scott Q. Nguyen, MD
Randolph Steinhagen, MD
Celia M. Divino, MD
Department of Surgery
Mount Sinai School of Medicine
New York, NY
Mr. X
A 25 year-old male presents with a 1 month
history of nausea, intermittent vomiting rightsided abdominal pain, bloating, episodic
diarrhea, fatigue, and weight loss.
History
What other information would be
helpful?
History, Mr.X
Consider the Following
• Characterization of
symptoms
• Temporal sequence
• Alleviating /
Exacerbating factors:
• Pertinent PMH, ROS,
MEDS.
• Relevant family hx.
• Associated signs and
symptoms
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
11
400
11
35
• Chem 7
135
110
30
3.4
23
1.0
• UA: Wnl
• FOBT: Positive
• Stool O & P: Negative
104
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 metronidazole
Moderate 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 Colitis
Transmural 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
Pseudopolyps
Cobblestoning
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
Acknowledgment
The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
feedbackPPTM@surgicaleducation.com