Reporter: liu qingxiangjs-ccqc.njzdyy.com/upload/2019-03-02/69739abb-866d-4788-ad83-574812c0... · schematic diagram The illustration shows the patient’s injury. Diagnosis: perforation

N Engl J Med 2019;380:473-85.

Reporter: liu qingxiang

Contents

01 02 03 04 05Presentation of the Case

Differential diagnosis

Clinical Diagnosis

Treatment & management

Discussion

Presentation of the Case

History of Present Illness

20 days before

19 days before

4 days before

At the tertiary care center

At Massachusetts General Hospital

caseAn 18-year old male

professional athlete was

admitted to hospital

because of fevers,

abdominal pain, and

hematochezia（便血）.


before 20 days

during a trip to the southeastern United States for athletic training

Ø fever

Ø Pain in the right lower

quadrant（右下腹痛）

umild postprandial nausea(餐后恶心) and loose stools （稀水便）

u P 59 Beats / min BP 114/65mmHgu enhanced ct of the abdomen and pelvis

normalu Blood level of electrolytes （电解质）calcium

（钙）, alkaline phosphatase ，total bilirubin ，and lipase were normal

before 19 days

Laboratory results

There were no obvious abnormal changes in the lab results


During the next 2 weeks

the abdominal pain diminished the fevers and loose stools resolved

The patient traveled with his team to the western United States and participated in reduced-intensity athletic training.


4 days before pain in the right lower quadrant recurred and was associated with low-back pain on the right side. produced well- formed stools that contained blood.

The following day • No bowel movement--A rectal suppository（直肠栓剂）

• bowel movement consisted of loose stools admixed with blood and mucus.

• T 39.7 developed


emergency department of the second hospital

HR: 110 beats/min BP: 124/76 mmHg RR 16 breaths/min T 38.9 °C SpO2: 99%(breath air)

The lower quadrants of the abdomen and the right flank were tender;

Results are shown in table 1

Main suit

symptom

Lab Results

MRI/CT Results are shown in figure 1

Vital signs

Pain in the right flank and abdomen and loss of appetite

Lab Results

CT

a contained, extraluminal, air-filled collection medial to the right common iliac artery (RCIA), with adjacent linear foci of gas that extend to the sigmoid colon

右侧髂总动脉(RCIA)内侧有一个包含腔外充满空气的集合，其邻近的气体病灶呈线状延伸至乙状结肠。

MRI

reportedly revealed mildly distended, fluid-filled loops of small bowel in the left half of the abdomen and the presence of air–fluid levels in the rectum.

treatment

• A c e ta m i n o p h e n（对乙酰氨基酚）a n d intravenous fluids were administered, and the fever and tachycardia resolved

The USA

The UK


1 day before admission ,in the outpatient clinical(门诊) of this hospital

T：36.3℃ HR: 84beats/min BP: 110/74 mmHg

Vital signs

Lab Results

Physical examination

The abdomen was soft, with normal bowel sounds; there was tenderness in the right lower quadrant and the suprapubic（腹股沟）region, without guarding, rebound tenderness, or masses.

The remainder of the examination was normal

Arrangements were made for an expedited Colonoscopy（结肠镜）to be performed the following afternoon.

Main suit Abdominal and back pain persisted with well-formed stools that contained blood


Next morning

light-headedness and malaise；negative for emesis（呕吐）, diarrhea, tenesmus（里急后重）, genitourinary symptoms,（泌尿系统） arthralgias（关节痛）, rash, and skin and oral ulcerations（溃疡）

symptom

after the bowel-preparation , a bowel movement that contained a large volume of blood. With shaking chills and fever, (Tmax 39.4°C), worsening pain in the right lower quadrant

In the emergency

Physical examination

• The abdomen was soft, with normal bowel sounds; • tenderness on palpation of the right lower quadrant and the suprapubic

region; an enlarged right inguinal lymph node（腹股沟淋巴结）.• Examination of the rectum a few external hemorrhoids（痔疮） with

scant bright-red blood in; no skin tags or palpable fissures（裂缝） or masses.


In the emergency

Lab Results Table 1

Blood culture was performed .Tests for infection with HIV,HBV,HCV and Helicobacter pylori （-）（幽门螺杆菌）.

other Results

Personal history He did not smoke tobacco, drink alcohol, or use illicit drugs.

Family historyThere was no family history of autoimmune diseases or inflammatory bowel disease.

T：40.2℃ HR: 145beats/min BP: 109/52 mmHg RR 35breaths/min SPO2 97%(breath Air)

Vital signs

Lab Results


Admitted to the hospital

• Klebsiella pneumoniae (肺炎杆菌)and gram-positive cocci/ kɒksaɪ /（球菌）.

• repeat blood cultures: a second type of gram-negative rod.

Blood culture Results

Question

Diagnosis？

• T：40.2℃ • HR: 145beats/min • BP: 109/52 mmHg • RR 35breaths/min• SPO2 97% (Air)

• abdomen soft, normal bowel sounds;

• tenderness on palpation of the r i g h t l o w e r q u a d r a n t ; a n enlarged right inguinal lymph node.

• a few external hemorrhoids with scant bright-red blood in;

• MRI mildly distended, fluid-filled loops of small bowel in the left half of the abdomen and the presence of air–fluid levels in the rectum.

• inflammatory marks NE 、CRP is high

• Blood culture is positive

04

05

06

03

02

Appendicitis阑尾炎

differential diagnosis01

07

04

05

06

03

02



07

• Was the pain in the right lower quadrant preceded by epigastric pain, was it localized to McBurney’s point？

• It is notable that the appendix was not visible on this patient’s initial imaging studies.in whom the appendix would appear thickened and swollen on Ct or MRI.

04

05

06

03

02

Appendicitis

阑尾炎

Diverticulitis憩室炎


07

04

05

06

03

02



07

• It would be helpful to know the ethnic background of the patient, because Asian patients most commonly have diverticulitis on the right side, in the cecum or ascending colon, whereas North American and European patients most commonly have diverticulitis on the left side, in the sigmoid colon, and present with this condition at an older age.

04

05

06

03

02

Appendicitis

阑尾炎

Inflammatory Bowel

Disease



07

04

05

06

03

02

Appendicitis

阑尾炎

Inflammatory Bowel

Disease



07

• This disease is 3 to 20 times as likely to develop in first-degree relatives of patients with Crohn’s disease as in the general population. the imaging studies do not show transmural thickening or inflammation of the bowel, skip lesions, creeping fat, or other hallmarks of Crohn’s disease, such as a fistulous(管状) tract.

04

05

06

03

02

Appendicitis

阑尾炎

Infectious Colitis Inflammatory

Bowel Disease



07

04

05

06

03

02

Appendicitis

阑尾炎

Infectious Colitis Inflammatory

Bowel Disease



07

• Infectious colitis that is due to organisms such as Salmonella enterica（肠道沙门氏菌）, Campylobacter jejuni（空肠弯曲杆菌

• ）, and Yersinia enterocolitica（耶尔森氏菌） should be considered in this case.

• This patient had an enlarged right inguinal lymph node but no other signs of colitis on CT, and his diarrhea subsided （停止）spontaneously.

04

05

06

03

02

Appendicitis

阑尾炎

Infectious Colitis

Colitis Associated with

Nonsteroidal Anti-

inflammatory Drugs

Inflammatory Bowel

Disease



07

04

05

06

03

02

Appendicitis

阑尾炎

Infectious Colitis


Nonsteroidal Anti-

inflammatory Drugs

Inflammatory Bowel

Disease



07

• given the history of ibuprofen use, could the use of ibuprofen have led to the colitis and abdominal pain?

• It could have led to increased bleeding from ulcerations in the colon. /stə'rɔidəl/

04

05

06

03

02

Appendicitis

阑尾炎

IschemicColitis

Infectious Colitis


Nonsteroidal Anti-

inflammatory Drugs

Inflammatory Bowel

Disease



07

04

05

06

03

02

Appendicitis

阑尾炎

IschemicColitis

Infectious Colitis


Nonsteroidal Anti-

inflammatory Drugs

Inflammatory Bowel

Disease



07

• In athletes, reversible ischemic bowel disease involving the cecum and ascending colon, with associated pain on the right side, may be due to physiological shunting caused by splanchnic(内脏的) vasoconstriction or to intravascular volume depletion, or it may result from other factors.

04

05

06

03

02

Appendicitis

阑尾炎

IschemicColitis

Infectious Colitis

Right Inguinal Hernia


Nonsteroidal Anti-

inflammatory Drugs

Inflammatory Bowel

Disease



07

04

05

06

03

02

Appendicitis

阑尾炎

IschemicColitis

Infectious Colitis



Nonsteroidal Anti-

inflammatory Drugs

Inflammatory Bowel

Disease



07

• this patient’s imaging studies do not show evidence of a hernia, and a targeted physical examination and ultrasonography of the groin（腹股沟） have not been mentioned.

04

05

06

03

02


IschemicColitis

Infectious Colitis



Nonsteroidal Anti-

inflammatory Drugs

Inflammatory Bowel

Disease


differential diagnosis

given the history of ibuprofen use, It could have led

to increased bleeding from

ulcerations in the colon.

0107

In athletes, reversible

ischemic bowel disease involving the cecum and

ascending colon

no evidence of a hernia, and a ultrasonography of the groin have not been

mentioned.

It would be helpful to know

the ethnic background of

the patient

This disease is 3 to 20 times as likely to

develop in first-degree relatives of

patients with Crohn’s disease as in the

general population.

Infectious colitis that is due to organisms

should be considered in this

case.

It is notable that the appendix

was not visible on this patient’s initial imaging

studies

cancer?

Foreign body?

colonoscopy

A 5-cm wooden toothpick was found lodged in the proximal sigmoid colon（乙状结肠）, 25 cm from the anal verge（肛

外缘）, and there was evidence that it had eroded the colon wall on one end.

Endoscopic evaluation was performed because neither the toothpick nor the resulting perforation was evident on the CT.

Treatment & management

• Endoscopic removal of the toothpick led to immediate pulsatile （脉动的）bleeding

• placement of nine hemostatic clips and administration of a total of 10 ml of epinephrine

The interventional radiology service performed angiography（血管造

影）, which revealed extravasation（泄漏） of contrast material from the right common iliac artery into the sigmoid colon （乙状

结肠）

schematic diagram

The illustration shows the patient’s injury.Diagnosis: perforation of the sigmoid colon by a foreign body ,with an adjacent（邻近的） abscess and a possible arterioenteric fistula（瘘管） involving the right common iliac（回肠）

An occlusion balloon was placed in the right common iliac artery.

The patient did well after surgery and was discharged on the 10th hospital day. At the time of discharge, he was able to walk without assistance.

Ending

THANKS

Documents

Reporter: liu qingxiangjs-ccqc.njzdyy.com/upload/2019-03-02/69739abb-866d-4788-ad83-574812c0... · schematic diagram The illustration shows the patient’s injury. Diagnosis: perforation