Download 七院聯合CPC 93年11月03日

七院聯合CPC
93年11月03日
鄧景升醫師/李春銘主治
三軍總醫院 小兒部
Chief complaints
• Progressive abdominal pain,
occasional vomiting, diarrhea and
intermittent high fever for six days
Present illness
• A two- year- old boy was in good
condition without any complaint of
abdominal symptoms before
presentation.
• He was referred to our pediatric clinic
with a six- day history of progressive
abdominal pain and intermittent high
fever.
• Vomiting and diarrhea were
occasionally accompanied with
abdominal pain.
• Appetite decreased.
Physical examinations
• BT: 39’C
• Abdomen: palpable mass on RUQ
of abdomen
Laboratory data
Initial laboratory data
• WBC: 16.2 X 109/ l
• Neutrophil: 83%
• ESR: 82 mm/h
• CRP: 8.8 mg/dl
• PPD skin test: negative
• Biochemical data: normal range
• Blood culture: pending result
• Stool culture: pending result
Hospital course
• After admission, KUB and abdominal
ultrasound were arranged.
• The abdominal ultrasound revealed a target
lesion on the RUQ of the abdomen  the
presumptive diagnosis of intussusception was
made at that time.
• Barium enema reduction was attempted but
failed to find intussusceptum.
• CT of abdomen was performed.
• The patient was placed at bowel rest, and
intravenous fluid were administration.
• A blood culture and stool culture were
obtained, and empirical antibiotic therapy was
initiated
Image studies
• KUB: non specific gas pattern
• Abdominal sonography: a target
lesion on the RUQ of the abdomen
• Barium enema: A radiopaque
filling defect with moth- eaten
margin in the ascending colon near
the hepatic flexure region.
Image studies
• CT of the abdomen: circumferential
thickening of the intestinal wall in
the ascending colon. The length of
the thickened segment was about
7 cm, and the wall thickenness
was about 2 cm
Questions to be asked
Questions: (1)
•
What was the pattern of abdominal pain? Location ?
 physical examination?
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•
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•
Vital sign?, BP, RR, PR?
Weight loss ?
Other signs of physical examination? Chest ?abdomen ?
Bowel sound? Rigidity? Soft ? Locate the site of
maximal pain? Tenderness? Pattern of palpable mass ?, etc.
Was there any other enlarged lymph nodes on physical
examination ?
 History?
•
•
•
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Did he have history of foreign travel ? Did he live with froeign
servant?
Was there family history of cancer ?
Have the patient drunk unpasteurized milk?
Did he have history of contact with a case of tuberculosis, a
parent ? or other family ?
Questions: (2)
Lab
• Stool routine? Stool pattern ? Bloody stool ?
Examination of stool specimens showed ova or
parasites?
• CBC-H, LDH, uric acid level ?
• Chest X-ray ?
• Was there any other findings on CT and barium enema ?
Another abnormal finding on other sites ? skip lesions ?
fissures, sinus tracts, fistulas ? Hepatosplenomegaly?
• Did CT scanning show any other lymphadenopathy in
this patient ?
• colonoscopic examination ?
• What are the patient’s
problems ??
Major Problems
• Palpable mass on RUQ
of abdomen
• Abdominal ultrasound
revealed a target lesion
on the RUQ
• Barium enema: a
radiopaque filling defect
with moth- eaten margin
in the ascending colon
near the hepatic flexure
region.
• CT of the abdomen:
circumferential
thickening of the
intestinal wall in the
ascending colon.
Minor Problems
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•
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•
•
Abdominal pain
High fever
Vomiting
Diarrhea
Leucocytosis
Elevation of ESR and
CRP
Target lesion
Abdmonial mass
high fever
location
Filling defect
Thickened bowel wall
Target lesion
• A target lesion at the
ultrasound scan indicating
thickened bowel wall
• On ultrasonography
encircling thickening of the
colonic wall (target sign).
Journal of Korean Medical Science. 15(4):371-9, 2000 Aug.
Target sign
Gastroenterology Clinics
Volume 31 • Number 3 • September 2002
• Neoplasms bowel wall
thickening  target sign or
“pseudokidney” sign
• Focal inflammatory or ischemic
masses.
• Perforating diverticulitis
• Ischemic colitis : "target lesion"
filling defect
• A lesion protruding into the lumen
 appear as a radiolucent filling
defect in the barium pool
• Mass lesion
• Ischemic colitis
• Amoebiasis– amoeboma
CT Diagnosis of the
Abnormal Bowel Wall
Radiographics. 2002;22:1093-1107
Thickened bowel wall
idiopathic inflammatory bowel
diseases,
infectious diseases,
radiation damage.
malignancy.
Causes of large-bowel
strictures
Physiological
• Spasm
• Distended bladder
Malignant
Annular carcinoma
Scirrhous carcinoma
Lymphoma
Diverticular disease
Muscle thickening
Pericolic abscess
Superimposed malignancy
Ischaemia
Radiation colitis
Inflammatory bowel disease
Ulcerative colitis
Crohn’s disease
Tuberculosis
Lymphogranuloma venereum
Amoebiasis
Extrinsic disease
Intra-abdominal masses
Metastatic carcinoma
Endometriosis
Pelvic lipomatosis
Cholecystitis
Pancreatitis
Miscellaneous
Postoperative anastomosis
Trauma
Hirschsprung’s disease
Malignant abdominal
masses (nonneonatal)
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Hepatic:
Hepatoblastoma
Hepatocellular
carcinomaRhabdomyosa
rcoma
(rare)Angiosarcoma (very
rare)
Renal
Wilms' tumor
Renal cell
carcinoma(rare)
Lymphoma (very rare)
Adrenal
Neuroblastoma
Adrenal cortical
carcinoma (rare)
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Gastrointestinal
Lymphoma
Carcinoid (appendix)
Teratoma
Carcinoma (very rare)
Lymphatic
Lymphoma
Other
Teratoma
Neuroblastoma,
sympathetic chain
Sarcoma
Pancreatoblastoma (very
rare)
Teratoma
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The sacrococcygeal region: most site.
most commonly in infants, at birth,
females
Carcinoid Tumors
• usually occur in the appendix in children
• outside the appendix (ileojejunum, colon) commonly
metastasize
• carcinoid syndrome  episodic intestinal hypermotility
and diarrhea, vasomotor disturbances (flushing) (75% to
90%) , bronchoconstriction (wheezing) (25%), and rightsided heart failure
• Barium enema: single or multiple filling defects in the
distended ileum
• Carcinoid tumors rarely occur in the large intestine
X
LYMPHOGRANULOMA
VENEREUM
• a systemic sexually transmitted
disease
• Chlamydia trachomatis causes
lymphogranuloma venereum. A
chronic proctitis is complicated by
fistula formation, extensive fibrosis,
and eventual stricture
formation.X
CT OF THE COLON
Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed
• Three basic patterns have been
described in benign disease:
(i) a homogeneous ring of bowel
wall >4 mm thick;
(ii) a double halo with alternating
layers of density;
(iii) target sign
Carcinoma
• Diagnosis: family history, endoscopic findings,
gastrointestinal bleeding, or obstruction.
• Symptoms are nonspecific abdominal pain, an
abdominal mass
• carcinoma does not follow a circumferential
pattern
• Rare in children, in early adulthood
• Scirrhous carcinoma may infiltrate diffusely
to present as a relatively smooth stricture. This
type of tumour is much more likely to be
metastatic from the stomach or breast than a
primary lesion
X
Target lesion
Abdmonial mass
High fever
Amebic colitis with ameboma
Infectious colitis (parasitic, viral)
Intestinal tuberculosis
Pericolic abscess
Inflammatory bowel disease(ulcerative
colitis and Crohn’s disease )
Lymphoma
Ischemic colitis
colon
Filling defect
Thickened bowel wall
PPD skin test
(Gershon: Krugman's Infectious Diseases of Children, 11th ed )
• A negative tuberculin skin test never rules
out tuberculosis in a child.
• The most common causes of false-negative :
incubation of viral infections
incubation of bacterial infections;
overwhelming tuberculosis;
recent administration of live viral vaccines;
severe malnutrition;
diseases and drugs causing anergy;
extremes of age (newborns and the elderly)
• False-negative TST : severe tuberculosis
disease soon after infection, those with
immunosuppressive illnesses, malnutrition, or
other severe infections.
(The Lancet Infectious Diseases Volume 3 • Number 10 • October 2003)
The Lancet Infectious Diseases
Volume 3 • Number 10 • October 2003
• Extra-pulmonary tuberculosis disease is more
common in children than adults, 25% of infants
and young children less than 4 years of age
• But extra-pulmonary manifestations of tuberculosis,
such as gastrointestinal or renal, are rare in
children because of long incubation periods
required following haematogenous dissemination
to manifest as disease.
• The rate of false-negative TST in children with
tuberculosis who are infected with HIV, is unknown,
but it is certainly higher than 10% and is
dependent on the degree of immunosuppression
(ie, CD4 counts).
Intestinal tuberculosis
• pain, diarrhea or constipation, and weight loss
with low-grade fever.
• primary bovine origin from drinking
unpasteurized milk, the chest radiograph being
normal. Question ?
• Ulcerative, hypertrophic or mixed forms are
described.
• The ulcers tend to be large and circumferential
with a shaggy edge,
• The hypertrophic form presents with an
inflammatory mass and stenosis of the bowel
lumen.
• palpable mass may be noted
• commonest in the ileocaecal region, but may
be seen in any part of the gastrointestinal tract
Intestinal tuberculosis
• a conical caecum with a patulous ileocaecal
valve and a dilated terminal ileum
• transverse ulceration, ulcerated stricture
sharply demarcated from normal bowel.
• Utrasound and CT : ascites, peritoneal
involvement, and lymphadenopathy.
• Caseous lymph nodes with a hypoechoic
centre on ultrasound, or peripheral
enhancement on CT, with ascites and a
thickened bowel wall are highly suggestive
of tuberculosis.
• caseous epithelioid granulomas (CGs) are
characteristic of tuberculosis.
Intestinal tuberculosis
• The diagnosis of extrapulmonary TB:
collecting specimens for AFB stain and
culture and sometimes for pathologic
diagnosis.
• PCR: rapid diagnosis of tuberculosis.
• PCR does not seem to be markedly
sensitive for intestinal tuberculosis.
Kim et al. found that the PCR was
positive in only 30% of fresh biopsy
specimens.
LYMPHOMA
• Usual < 3y/o
• Lymphoma is the most common malignancy of
the gastrointestinal tract in children
• Primary lymphoma of the colon is rare and
non-Hodgkin’s in type.
• stomach, distal ileum, cecum, or appendix and
may present as crampy abdominal pain,
vomiting, distention, or a palpable abdominal
mass.
• Mild fever.
• The caecum or rectum are usually involved,
as these sites contain the most lymphoid
tissue.
• The most common location was ileum
LYMPHOMA
• A large polypoid mass or annular
lesion is typical
• Annular infiltration involving a long
segment of >5 cm, with deep
fissuring, cavitation, and a large
extraluminal component, are
features that suggest lymphoma.
• X
Diverticular disease
• Diverticular disease is recognized
radiologically from its two main components —
the muscular abnormality and the diverticula.
• commonest in sigmoid lesions, rare in
caecal lesions
• there is left-sided abdominal pain, tenderness,
and some fever.
• The presence of diverticular disease :
thickening of the muscle wall, and the
presence of extramural gas bubbles or
pockets of fluid within the diverticula. X
• Diverticular disease is a common
abnormality in the elderly  X
• interdigitating folds
Pericolic abscess
• Perforation of a diverticulum  an
inflammatory reaction in and around the wall of
the colon,  segmental narrowing
• Plain radiographs : localized ileus, a softtissue mass or, rarely, gas within the abscess.
• A water-soluble contrast enema: tracking from
a ruptured diverticulum
• CT: wall thickening >4 mm of homogeneous
density, and the presence of gas or contrast
medium in the diverticula outpouches.
• fine stranding, a fluid collection with gas
bubbles or a fluid level is diagnostic of an
abscess.
• the ‘saw-tooth’ pattern ( fibrosis), which may
be ‘draped’ around the site of the abscess.
Inflammatory bowel
diseases
•
onset at 15–25 yr of age and a
second smaller peak at 50–80 yr
of age. X
•
Diarrhoea, fever and malaise are
common to both.
Abdominal pain and a tender mass
are more typical of Crohn’s disease,
chronic diarrhea of greater than 4
weeks' duration.
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•
Ulcerative colitis
Radiographic imaging of inflammatory bowel disease
Gastroenterology Clinics Volume 31 • Number 1 • March 2002
 Double- contrast barium enema
• fill with barium creating the granular --typical of
ulcerative colitis--X
• Deeper ulcers  collar-button ulcers– X
• rectal bleeding -- ulcerative colitis
 In advanced disease
• ulcerative colitis is characterized by a pancolitis with
diffuse ulceration, or absent haustral folds,
thumbprinting, and narrowing or shortening of the colon,
most commonly in the rectosigmoid
 Computed tomography
• CT: mural thickening
• the mean wall thickness is 8 mm, (normal colon is only 2 to 3 mm)
• inhomogeneous enhancement of the colonic wall
• This enhancement results in a classic target or double
halo sign
Crohn's disease
• a chronic idiopathic granulomatous process
characterized by transmural inflammation of
the bowel, often associated with the
development of fissures, sinus tracts, fistulas,
and abscesses  question ?
• Large anal skin tags (1–3 cm diameter) or
perianal fistulas  question?
• discontinuous skip lesions between areas of
uninvolved bowel question ?
• most terminal ileum and proximal colon,
isolated colonic disease in 20% to 27%
• may involve the gastrointestinal tract
anywhere from the mouth to the anus
• chronic phase: circumferential thickening of
the bowel wall, irreversible strictures in the
small bowel or colon
Crohn's disease
Barium studies
• the small bowel is involved in up to
80% of cases question?
• The earliest radiographic findings
of Crohn's disease in the small
bowel or colon are aphthous ulcers
(collections of barium surrounded by radiolucent halos)
• development of a cobblestone
most commonly occurs in the small
bowel .
Crohn's disease
Computed tomography
• the most common : mural
thickening
• Average wall thickness of 11 to 13
mm in the small bowel or colon
• Mural thickening is most common
in the terminal ileum: thickness of
2 cm
• fistulas and sinus tracts 20% to
40% of cases
• Colonoscopy with biopsy in
establishing a diagnosis.
ISCHAEMIC COLITIS
• the systemic manifestations of cardiac
arrhythmia, myocardial infarction, and
congestive heart failure
• abdominal pain and rectal bleeding of sudden
onset.
• The mucosa  oedema thumbprinting
• mosaic’ pattern
• The splenic flexure and the descending colon
are the commonest sites (watershed between the
superior and inferior mesenteric arteries). X
• The rectum and ascending colon are rarely
involved
• Ischaemia is usually segmental, involving
about a 19-cm length.
Thumbprinting
Mosaic pattern in early ischaemic colitis
Amebic colitis
• Amebic colitis affects all age groups, but its
incidence is strikingly high in children 1–5 yr of
age.
• a granular mucosa
• The radiological features of invasive
amoebiasis include a segmental or diffuse
colitis, with a granular or ulcerated mucosa.
• Aphthoid ulceration may be seen, and
amoeboma formation occurs in about 10% of
cases.
• inflammatory granulation masses cause an
irregular stricture
• luminal narrowing on a barium-enema
examination  ameboma.
• Tender, palpable, abdominal mass.
Amebic colitis
• they are often multiple and are usually
found at the flexures and the caecum.
• Ameboma results from the formation of
annular colonic granulation tissue at a
single site or multiple sites, usually in
the cecum or ascending colon. An
ameboma may mimic carcinoma of the
colon
Amebic colitis
• history of cramping abdominal pain,
weight loss, and watery or bloody
diarrhea.
• Infection with Entamoeba
histolytica may be asymptomatic or
may cause dysentery
• The insidious onset and variable
signs and symptoms make
diagnosis difficult, with fever and
grossly bloody stool absent in most
cases.
luminal narrowing (arrow) on a barium-enema
examination in a patient with ameboma.
INFECTIOUS COLITIS
• Salmonella, Shigella and
Campylobacter may all present
with a localized or diffuse colitis,
with a granular or ulcerated
mucosa.
• marked ileus
• profuse, watery diarrhea, rectal
bleeding, and edematous mucosa
in the rectum
PSEUDOMEMBRANOUS
(ANTIBIOTIC-ASSOCIATED)
COLITIS
• Broad-spectrum antibiotics or chemotherapy
may predispose to an overgrowth of the Grampositive Clostridium difficile
• diarrhoea, pyrexia, and leukocytosis.
• Plain radiographs may show a generalized
ileus.
• CT and ultrasound may detect ascites and a
thickened colonic wall.
• Nodular haustration
• stool specimen for the C. difficile toxin
VIRAL COLITIS
• ileocecal area, in immunocompetent persons.
• Cytomegalovirus (CMV) causes a vasculitis
with a thick wall, lymphadenopathy and large
ulcers that may bleed, and is typically ileocolic
in distribution X
• Tissue staining for cytomegalovirus
• CT will show a thickened bowel wall,
mesenteric lymphadenopathy, and often
ascites.
• The herpes simplex virus is associated with a
proctitis and multiple more superficial ulcers.
X
PARASITIC COLITIS
• In trichuriasis (鞭蟲病)small coiled worms
may be seen on the mucosal surface.X
• Strongyloides stercoralis may simulate
ulcerative colitis. X
• In Chagas’ disease a megacolon results from
the neurotoxic effect of the protozoon
Trypanosoma cruzi.
• In schistosomiasis ova are deposited in the
submucosa of the large bowel. The
inflammatory response results in the formation
of numerous polyps. Fibrosis may later cause
stricture formation and calcification may be
visible in the bowel wall.X
Impression
• Amebic colitis with ameboma(Most
favored)
• Intestinal tuberculosis
• Crohn's disease
Diagnostic procedure
• Stool routine  leukocye, or identifying
cysts or motile trophozoites on a saline
wet mount of a stool specimen.
• The diagnosis of extrapulmonary TB
depends on collecting specimens for
AFB stain and culture and sometimes
for pathologic diagnosis.
• Endoscopy and biopsies
Diagnostic procedure
Therapy
Amebic colitis
• Invasive amebiasis of the intestine, liver, or
other organs requires the use of
metronidazole (30–50 mg/kg/24 hr divided tid
PO for 10 days; maximum: 500–
750 mg/dose), a tissue amebicidal drug.
• The recommended regimen for treating
asymptomatic cyst carriers is iodoquinol (30–
40mg/kg/24hr divided tid PO for 20 days;
maximum: 650mg/dose). Paromomycin, a
nonabsorbable aminoglycoside, is an
alternative.