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TRANSCRIPT
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).
Presentation of the Case
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
Presentation of the Case
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.
Presentation of the Case
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
Presentation of the Case
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
Presentation of the Case
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
Presentation of the Case
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.
Presentation of the Case
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
Presentation of the Case
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
Appendicitis阑尾炎
differential diagnosis01
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
differential diagnosis01
07
04
05
06
03
02
Diverticulitis憩室炎
differential diagnosis01
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
Diverticulitis憩室炎
differential diagnosis01
07
04
05
06
03
02
Appendicitis
阑尾炎
Inflammatory Bowel
Disease
Diverticulitis憩室炎
differential diagnosis01
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
Diverticulitis憩室炎
differential diagnosis01
07
04
05
06
03
02
Appendicitis
阑尾炎
Infectious Colitis Inflammatory
Bowel Disease
Diverticulitis憩室炎
differential diagnosis01
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
Diverticulitis憩室炎
differential diagnosis01
07
04
05
06
03
02
Appendicitis
阑尾炎
Infectious Colitis
Colitis Associated with
Nonsteroidal Anti-
inflammatory Drugs
Inflammatory Bowel
Disease
Diverticulitis憩室炎
differential diagnosis01
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
Colitis Associated with
Nonsteroidal Anti-
inflammatory Drugs
Inflammatory Bowel
Disease
Diverticulitis憩室炎
differential diagnosis01
07
04
05
06
03
02
Appendicitis
阑尾炎
IschemicColitis
Infectious Colitis
Colitis Associated with
Nonsteroidal Anti-
inflammatory Drugs
Inflammatory Bowel
Disease
Diverticulitis憩室炎
differential diagnosis01
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
Colitis Associated with
Nonsteroidal Anti-
inflammatory Drugs
Inflammatory Bowel
Disease
Diverticulitis憩室炎
differential diagnosis01
07
04
05
06
03
02
Appendicitis
阑尾炎
IschemicColitis
Infectious Colitis
Right Inguinal Hernia
Colitis Associated with
Nonsteroidal Anti-
inflammatory Drugs
Inflammatory Bowel
Disease
Diverticulitis憩室炎
differential diagnosis01
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
Appendicitis阑尾炎
IschemicColitis
Infectious Colitis
Right Inguinal Hernia
Colitis Associated with
Nonsteroidal Anti-
inflammatory Drugs
Inflammatory Bowel
Disease
Diverticulitis憩室炎
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