Case Study

• Chayamon Suwansumrit 54107010029

• Chatsaran Thanapongpibul 54107010037

• Nantanan Jengseubsant 54107010080

• Ninlaksami Chinkamolthong 54107010082

• Punnapat Yookong 54107010093

• Pattara Karnjanakan 54107010103

• Wiyakorn Supapanyapong 54107010124

• Sasicha Yingyeunyong 54107010127

Case Information

• Case : 72-year-old Thai, Prachinburi-based

male

• Chief complaint : Progressive abdominal pain

for 1 day PTA

Present illness

3 weeks PTA, He had a severe tenesmus

after he ate 8 pieces of Kanom-Tein in the

morning. He went to Ban Sang hospital for an

enema administration

After the procedure was done, he passed a

plenty of normal stool but the pain did not

relieve. Then he was referred to Aphaiphubeth

hospital for admission and had been there for 15

days, the symptoms improved and he was

discharged.

Case Information (cont.)

Case Information (cont.)

1 day PTA, He complained of a sudden-

onset of intermittent abdominal pain, it took

about 5-10 seconds to a pain-free period. The

pain did not related to any meal or activity.

On that day he passed stool for 3 times, no

blood clot or mucous was seen but he noticed

that the stool caliber was smaller than before.

He also had history of anorexic symptoms,

nausea, vomiting, mild constipation and his

body weight decreased from 71 to 66

kilograms within 3 weeks.

Case Information (cont.)

Past history

–Underlying disease

• BPH

• Hypertension

• DM (Follow up at Bansang hospital,

baseline FBS 140-150 mg%)

• DLP (good control)

• Pterygium both eyes

Past history (cont.)

–Current medication : underlying disease

medication

–Surgical history

• S/P appendectomy 40 years PTA

–No accidental history

–No history of drug or food allergy

Past history (cont.)

–Alcohol drinking 1-2 glasses per day for 30

years

–No smoking

–No history of using herbs, boluses, decoctums

– Family history : his father had lung cancer

(dead)

Past history (cont.)

–Hospital admission history :

• 11-19 August 2014 at Aphaiphubeth hospital

Dx : Gut obstruction with pancreatitis

• 22 August 2014 at Aphaiphubeth hospital

ultrasound abdomen and acute abdomen

series : normal

Physical examination

• Vital signs :

–BT 38.0°C

–BP 138/77 mmHg

–RR 20 /min

–PR 90 bpm

• General appearance : A Thai old male, good

consciousness, not pale, no jaundice

• HEENT : moderately pale conjunctiva, dirty

sclera

• CVS : normal S1S2, no murmur

Physical examination (cont.)

Physical examination

• RS : normal breath sound

• Abdomen : mild distention, surgical

scar at RLQ, hyperactive bowel

sound, soft, generalized tender, no

rebound tenderness, no guarding

• Extremities: no pitting edema

• Per rectal examination: yellow feces, normal

sphincter tone, no feces impact

Physical examination (cont.)

Positive findings

• Sudden-onset of intermittent abdominal pain

with pain-free period

• History of severe tenesmus

• Abnormal stool passing with decreased stool

caliber

• Anorexia with significant weight loss

• Nausea and vomiting

Problem lists

• Generalized abdominal pain with decreased

stool caliber 1 day PTA

• History of tenesmus with loss of appetite and

significant weight loss 3 weeks PTA

Differential diagnosis

• Large bowel obstruction

• Small bowel obstruction

Provisional diagnosis

• Partial gut obstruction

LABORATORY

INVESTIGATION

Complete Blood Count (1/9/57)

• Hb 9.8 g/dL

• Hct 30.4 %

• WBC count 12,160 cells/mm³

–Neutrophil 80.1 %

–Lymphocyte 10.2 %

• Platelet count 597,000 cells/mm³

Blood chemistry (1/9/57)

• Na 132 mEq

• K 4.32 mEq

• Cl 97.2 mEq

• HCO3 22.6 mEq

• BUN 18.4 mg/dL

• Cr 0.93 mg/dL

Coagulation (1/9/57)

• PT 14.8 sec

• PTT 28.4 sec

• INR 1.25

Urinalysis (1/9/57)

• Yelllow, clear

• Sp.Gr 1.015

• pH 5.0

• Leukocyte neg

• Nitrite neg

• Protein trace

• Glucose 1+

• Ketone neg

• Urobilinogen neg

• Bilirubin neg

• Erythrocyte trace

• WBC 0-1/HPF

• RBC 0-1/HPF

• Epithelial cell 0-1/HPF

FILM ACUTE ABDOMEN SERIES SEPTEMBER 1ST ,2014

Findings

• Film chest X-Ray AP upright

–No free air under dome of diaphragm

–No infiltration or effusion both lung fields.

Findings

• Film abdomen supine

–Markedly dilatation of large bowel

–No air in rectum was seen

–Liver and spleen can not be evaluated

–Normal psoas muscle shadow both sides

–No widening paracolic gutter

–Normal bony structure

Findings (cont.)

Findings

• Film abdomen upright

–Markedly dilatation of large bowel with

air-fluid level was seen as “Different

height in the same loop”

–Liver and spleen can not be evaluated

–No free air under dome of diaphragm

–Normal psoas muscle shadow both sides

–No widening paracolic gutter

–Normal bony structure

Findings (cont.)

FILM ABDOMEN SUPINE SEPTEMBER 2ND ,2014

Findings

• Film abdomen supine

–Markedly dilatation of ascending,

transverse and descending colon

–No air in rectum was seen

–Liver and spleen can not be evaluated

–Normal psoas muscle shadow both sides

–No widening paracolic gutter

–Normal bony structure

Findings (cont.)

FILM ABDOMEN UPRIGHT SEPTEMBER 2ND ,2014

Findings

• Film abdomen upright

–Markedly dilatation of large bowel with

air-fluid level was seen as “Different

height in the same loop”

–Liver and spleen can not be evaluated

–No free air under dome of diaphragm

–Psoas muscle shadows were not seen

–No widening paracolic gutter

–Normal bony structure

Findings (cont.)

CT SCAN WHOLE ABDOMEN

WITH CONTRAST

(CORONAL VIEW) SEPTEMBER 2ND ,2014

Findings

• Markedly dilatation of ascending, transverse

and proximal part of descending colon

• Thickening wall of distal part of descending

colon at L4 paravertebral level measured 55.14

mm in length

CT SCAN WHOLE ABDOMEN

WITH CONTRAST

(AXIAL VIEW) SEPTEMBER 2ND ,2014

Findings

• Markedly dilatation of ascending, transverse

and proximal part of descending colon

• Thickening wall of distal part of descending

colon measured 20.2 mm in width

Conclusion

• A 72-year-old Thai male with CC of

abdominal pain for 1 day PTA. Plain film in

acute abdomen series shows and “Different

height in the same loop”. CT scan shows

thickening wall of distal part of descending

colon.

• Diagnosis : Large bowel obstruction due to

colonic mass

Treatment

Principles of treatment:

–En bloc resection

–Additional treatment

• Chemotherapy : stage III

–5 Fluorouracil and Leucovorin

–Oxaliplatin (NCCN recommended)

Treatment

–Follow up : 1-2 years

• First 2 years : Follow up every 3 months

• 2-5 years : Follow up every 6 months

• After 5 years : Follow up annually

KNOWLEDGE

CT scan

• Diagnosing and staging colorectal carcinoma

–Accuracy 45-77% asses nodes and metastases

– Insensitive to small masses

• Findings

–Soft tissue density, ulceration, narrow lumen

–Occasionally low-density masses and

calcifications in mucinous adenocarcinoma

• Complications may also be evident

MRI

• Accuracy 73% and sensitivity 40% for lymph

node metastases

• MR is having an increasing role to play in the

staging of rectal cancer.

Barium enema

• Sensitivities for polyps >1 cm

–Single contrast: 77-94%

–Double contrast: 82-98%

• Polyps <1 cm: < 50% detection

• Findings:

–Macroscopic appearance as filling defects.

–Exophytic, sessile, circumferential masses

–Fistulas may also be demonstrated.

Apple-core lesion

• The appearance of the apple-core lesion of the

colon also can be caused by other diseases

• Differential diagnosis

– Lymphoma

– Crohn’s disease

– Chronic ulcerative

colitis

– Ischaemic colitis

– Chlamydia infection

– Colonic tuberculosis

– Helminthoma

– Colonic amoebiasis

– Colonic

cytomegalovirus

– Villous adenoma

Take home message

• Signs of gut obstruction in plain film

–Markedly bowel dilatation of the proximal

portion of obstruction

• Small bowel > 2.5 cm in diameter

• Large bowel > 5 cm in diameter

– “Stepladder pattern” of small bowel in

supine position

Take home message

–Disproportion of air between small bowel

and large bowel

– “Different height in the same loop” of air-

fluid level in upright position

– In chronic case, the “string of beads” may

presents in upright position