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General and Colorectal
CASE 9: DiFFerential DiagnoSiS oF loWer abDominal pain
history
A 22-year-old woman presents to the emergency department complaining of lower abdominal pain. This has steadily increased in severity over the previous 24 h and woke her from her sleep. The pain is constant, and simple analgesia has not helped. She has vomited once in the department. Her menses are regular and she is now on day 12 of her cycle. There is no history of vaginal discharge or urinary symptoms. She has no children. She has not undergone any previous surgery but has a history of sexually transmitted disease 2 years ago, treated with antibiotics. There is no other relevant medical history. She takes no current medication and has no allergies. She is a non-smoker.
examination
Her blood pressure is 110/72 mmHg and pulse rate is 110/min. Her temperature is 38.2°C and there is lower abdominal tenderness, more marked in the right iliac fossa, with some rebound tenderness. There are no palpable masses and the loins are not tender. Digital rectal examination is normal. Bimanual per vaginal examination reveals adnexal tenderness on the right.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
14.7 g/dl |
11.5–16.0 g/dl |
White cell count |
16.6 × 109/l |
4.0–11.0 × 109/l |
platelets |
367 × 109/l |
150–400 × 109/l |
Sodium |
139 mmol/l |
135–145 mmol/l |
potassium |
4.1 mmol/l |
3.5–5.0 mmol/l |
urea |
5.6 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
74 μmol/l |
44–80 μmol/l |
C-reactive protein (Crp) |
145 mg/l |
<5 mg/l |
urine dipstick: naD (nothing abnormal detected) urinary b human chorionic gonadotropin (hCg): negative
Questions
•What is the differential diagnosis?
•How should the patient be managed initially?
•If you are unsure of the diagnosis, how should you proceed?
17
100 Cases in Surgery
ANSWER 9
The two main differential diagnoses are pelvic inflammatory disease and acute appendicitis. The young female with right iliac fossa pain is often difficult to diagnose. The other differential diagnoses of right iliac fossa pain mimicking appendicitis are shown below.
!Differential diagnoses
•Gynaecological
•pelvic inflammatory disease (salpingitis, salpingo-oophoritis, tubo-ovarian abscess, endometritis, Fitz-hugh–Curtis syndrome)
•ruptured ovarian cyst
•ovarian torsion
•haemorrhage/rupture of ovarian mass
•Surgical
•Crohn’s disease
•mesenteric adenitis
•gastroenteritis
•Diverticulitis (caecal or left sided with a floppy sigmoid lying centrally or on the right of the midline)
•meckel’s diverticulitis
•acute cholecystitis
•Urological
•acute pyelonephritis
•ureteric colic
The high white cell count, raised CRP and tenderness in the right iliac fossa make appendicitis the most likely diagnosis in this patient. In clear-cut cases of appendicitis, the patient is taken to theatre for appendicectomy. If the diagnosis is most likely gynaecological, the patient should be referred to the gynaecologists for a transvaginal ultrasound scan and high vaginal swabs. Where there is doubt, the patient can be taken for diagnostic laparoscopy. If the appendix is abnormal, it can then be removed laparoscopically.
KEY POINT
• a full gynaecological history should be taken in female patients.
18
General and Colorectal
CASE 10: Small-boWel anomaly
history
A 14-year-old boy presented to the emergency department with a 24- h history of increasing abdominal pain. The pain localized to the right iliac fossa and a diagnosis of acute appendicitis was made. At operation, the appendix was found to be normal and the anomaly shown in Figure 10.1 was found in a loop of small bowel.
Figure 10.1 operative picture of the small bowel.
Questions
•What is the diagnosis?
•What are the characteristics of this anomaly?
•How can this present?
•How would you deal with this intraoperative finding?
19
100 Cases in Surgery
ANSWER 10
The photograph demonstrates a Meckel’s diverticulum located on the anti-mesenteric border of a segment of ileum. This is a remnant of the omphalomesenteric duct. The ‘rule of twos’ is associated with this condition, i.e. it is present in 2 per cent of the population, it is 2 inches long and located 2 feet from the ileocaecal valve. A Meckel’s diverticulum may be lined by small-intestinal, colonic or gastric mucosa, and it may contain aberrant pancreatic tissue.
The mode of presentation may be:
•Inflammation and perforation of the diverticulum presenting with abdominal pain and peritonitis, mimicking acute appendicitis
•Rectal bleeding from peptic ulceration caused by acid secretion from the ectopic gastric mucosa
•Intestinal obstruction from intussusception or entrapment of the bowel in a mesodiverticular band or a fibrous band that may connect the apex of the diverticulum to the umbilicus or anterior abdominal wall
Tumours may also develop inside a Meckel’s diverticulum.
The diverticulum should be removed by a segmental small-bowel resection. A symptomless diverticulum that is an incidental finding at laparotomy should not be excised, but the patient should be informed of its existence.
KEY POINT
•patients should be made aware if an asymptomatic meckel’s diverticulum is found at the time of surgery.
20
General and Colorectal
CASE 11: a reCtal maSS
history
A 70-year-old man was seen in the surgical outpatient clinic complaining of a 3-month history of loose stools. He normally opens his bowels once a day, but has recently been passing loose motions up to four times a day. The motions have been associated with the passage of blood clots and fresh blood mixed within the stools. His appetite has been normal, but he reports a 2-stone weight loss. The past history was otherwise unremarkable. His father died from cancer at the age of 45 years, but he is unsure of the origin.
examination
No pallor or lymphadenopathy is present. The abdomen is soft and non-tender with no palpable masses. Digital rectal examination is normal.
INVESTIGATIONS
rigid sigmoidoscopy reveals a mass located approximately 11 cm from the anal verge (Figure 11.1).
Figure 11.1 lesion on sigmoidoscopy.
Questions
•What is the likely diagnosis?
•How should the patient be investigated?
•What are the options for treatment?
21
100 Cases in Surgery
ANSWER 11
A sessile mass is seen occupying approximately half of the bowel wall circumference. A biopsy of the lesion should be taken at the time of sigmoidoscopy to confirm the diagnosis of rectal cancer.
Blood tests including full blood count, liver function tests and tumour markers (e.g. carcinoembryonic antigen [CEA]) should be arranged. An urgent colonoscopy is required to determine whether there are any synchronous cancers (5 per cent) or synchronous polyps (75 per cent) in the rest of the large bowel.
The patient should be staged using computerized tomography (CT) of the chest and abdomen to check for chest, mediastinal and intra-abdominal metastases. Magnetic resonance imaging (MRI) of the pelvis is used to ascertain the depth of tumour invasion through the rectal wall and any regional nodal metastases. For tumours located above approximately 5 cm from the anal verge, an anterior resection is carried out with or without a temporary defunctioning stoma. If the tumour is less than 5 cm from the anal verge, then abdomino-perineal resection of the anus and rectum maybe required with a permanent end colostomy.
For tumours penetrating the rectal wall, preoperative radiotherapy is beneficial, and more recently a combination of chemotherapy and radiotherapy has been advocated for some tumours.
22
General and Colorectal
CASE 12: inveStigation oF anaemia
history
A 68-year-old man is referred by his general practitioner (GP) with a 6-week history of lethargy and breathlessness on walking. He is off his food and has lost 2 stone in weight over the previous 2 months. He reports no rectal bleeding or change in bowel habit. His father died at the age of 58 years from a colonic tumour. He is otherwise well and not on any regular medication. His GP referred him to the colorectal clinic, as he was concerned about his blood results and his strong family history of colorectal cancer. An OGD had been previously requested by the GP and was normal.
examination
On examination, his conjunctivae are pale and he looks cachectic. There is no jaundice or palpable lymphadenopathy. The chest is clear and the heart sounds are normal. Examination of the abdomen reveals a fullness in the right iliac fossa. There is no associated hepatomegaly. Digital rectal examination and sigmoidoscopy to 18 cm are normal.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
7.4 g/dl |
11.5–16.0 g/dl |
mean cell volume |
68 fl |
76–96 fl |
White cell count |
6 × 109/l |
4.0–11.0 × 109/l |
platelets |
250 × 109/l |
150–400 × 109/l |
Sodium |
132 mmol/l |
135–145 mmol/l |
potassium |
3.8 mmol/l |
3.5–5.0 mmol/l |
urea |
16 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
6.2 μmol/l |
44–80 μmol/l |
a Ct scan of the abdomen and pelvis (Figure 12.1) is organized.
Figure 12.1 Computerized tomography of the abdomen.
Questions
•How should microcytic anaemia be investigated?
•What is the diagnosis shown on the CT scan?
•What further investigations are required for this patient?
•What treatment is appropriate?
23
100 Cases in Surgery
ANSWER 12
Iron-deficiency anaemia should be firstly confirmed by a low serum ferritin, red cell microcytosis or hypochromia. The patient should then have their urine checked for haematuria, a rectal examination, and should be screened for coeliac disease. OGD and colonoscopy should be performed to exclude malignancy. One of the most common causes of iron-deficiency anaemia is from medications such as aspirin or other non-steroidal anti-inflammatory drugs.
The CT scan in this patient shows a caecal tumour. These can present insidiously and may only present with iron-deficiency anaemia. Further investigations should include liver function tests and a CEA tumour marker level. A CT scan of the chest, abdomen and pelvis will delineate the nature of the mass and any metastatic disease. A colonoscopy provides a tissue diagnosis and will rule out any synchronous tumours in the large bowel.
In the absence of metastatic disease, the patient should undergo right hemicolectomy. Adjuvant chemotherapy may be required, depending on the depth of the resected tumour and involvement of the local lymph nodes. If metastatic disease is present, then a palliative resection should be considered in patients with anaemia or obstruction.
KEY POINT
• Serum ferritin should be checked in patients with microcytic anaemia.
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