RADY 401 Case Presentation Sasha McEwan | 19 August 2019
In Initial patient his istory ry and workup • Jane Doe is a 38-year-old female with no significant PMH who initially presented to the emergency department with abdominal pain and mild leukocytosis, discharged without imaging or intervention. • Re-presented five days later with right lower quadrant abdominal pain • Vitals: T 97.9 F | BP 100/62 | HR 83 • Physical exam • Abdomen soft, RLQ tenderness just above McBurney point. Guarding and rebound tenderness present. • Lab data • WBC 13.1 • Beta HCG negative
Im Imaging stu tudies obtained • CT Abdomen/Pelvis with IV Contrast
Im Imaging stu tudies obtained CT Abdomen/Pelvis with IV contrast, axial planes GI Tract Findings: Edematous and dilated appendix with luminal discontinuity at the tip and adjacent free air.
Re Re-presentation to ED following appendectomy • Initial outcome: Patient underwent laparoscopic converted to open appendectomy secondary to significant inflammation. Completed four days of Zosyn and was not reimaged prior to discharge 8 days later • Four days after discharge, returned to emergency department with 2 days of lower abdominal pain and pressure and subjective fever • Afebrile, BP 95/61 • WBC 17.5 • Physical exam: mildly tender to palpation in bilateral lower abdominal quadrants, incisions clean, dry and intact with no swelling or erythema
Imaging stu Im tudies obtained CT Abdomen/Pelvis wit ith IV IV contrast, , axia ial pla planes Findings: Sequelae of recent appendectomy with phlegmonous changes along the mesentery of the mid-pelvis with mild peripheral enhancement, mesenteric stranding and free fluid along the site of the appendectomy with tiny locules of extraluminal gas.
Im Imaging stu tudies obtained CT Abdomen/Pelvis wit ith IV IV contrast, , cor oronal l pla plane Findings: Sequelae of recent appendectomy with phlegmonous changes along the mesentery of the mid-pelvis with mild peripheral enhancement, mesenteric stranding and free fluid along the site of the appendectomy with tiny locules of extraluminal gas.
Sm Small bowel in inter-loop abscess – Patient course • Readmitted to SRH and started on Zosyn • VIR consult – no safe window for aspiration of ill-defined abdominal fluid collection, consider repeat imaging and consultation if patient acutely worsened • Discharged on hospital day 4 with improved symptoms and leukocytosis with a one-week course of Augmentin • Readmitted two weeks later with same symptoms and leukocytosis to 18.5
Im Imaging stu tudies obtained Prio rior CT New CT Interloop abscess measures 3.8 x 4.0 x 5.5 cm (previously approximately 3.2 x 2.4 x 4.8 cm) CT Abdomen/Pelvis wit ith IV IV contrast, , axia ial pla planes Impression: Interval increase in size of the known interloop abscess adjacent to the postappendectomy surgical line with associated mesenteric stranding and peritoneal thickening and enhancement; mildly increased free fluid within the pelvis.
Im Imaging stu tudies obtained Prio rior CT New CT Interloop abscess measures 3.8 x 4.0 x 5.5 cm (previously approximately 3.2 x 2.4 x 4.8 cm) CT Abdomen/Pelvis wit ith IV IV contrast, , cor oronal l pla planes Impression: Interval increase in size of the known interloop abscess adjacent to the postappendectomy surgical line with associated mesenteric stranding and peritoneal thickening and enhancement; mildly increased free fluid within the pelvis.
Follow up Outcome • Discharged on 2 weeks of Flagyl and Augmentin. • Plan for 2 week follow up imaging in clinic to determine definitive treatment. • Two week CT: Interval decrease in size of known interloop abscess, now measuring a maximum dimension of 3 cm, with surrounding mesenteric stranding.
Abdominal abscess • ACR: CT Abdomen/Pelvis with IV contrast usually appropriate for acute, nonlocalized abdominal pain • Generally avoided in post-operative patients as fluid collections are often present but not infected and may lead to unnecessary treatment • Ultrasound • Fast, avoids ionizing radiation, good for evaluation of more complex collections • Limited use for deeper soft tissue infections or for collections adjacent to bowel • Used to screen for superficial fluid collections or for collections adjacent to solid organs • CT • Usually first-line modality in patients with fever of unknown origin • Used to detect deeper collections with IV and/or oral contrast to help distinguish from adjacent bowel or vasculature - CT: 300 300 to o 5000 5000 dolla dollars, ult ultrasound clo closer to o 250 250 - Rad adiation: CT 5-10 10 msV sV, , ult ultrasound non none - No o exact sen sensit itivity and and spe specificity rep reported du due to o such such a a var varie ied pre presentation
findings 3 Abdominal abscess: ty typical CT CT fi • Will typically have a low-attenuation central necrotic component • Well-defined capsule that may be thicker and more irregular than a typical cystic wall • Capsular ring enhancement with contrast • Surrounding peritoneal fat stranding • Mass effect with adjacent structures
Treatment options • Varies based on patient status and body habitus, institution, size and location of the collection, etc. • Antibiotics and supportive treatment +/- needle aspiration of fluid collection for drainage or to narrow antibiotic regimen • Percutaneous drainage • Usual treatment for large (>4-5 cm) collections, if possible • Endoscopic drainage • Immediate or delayed surgery
Take-home points • Routine imaging of post-operative patients is not encouraged • Ultrasound is fast and does not utilize ionizing radiation; however, it is not useful for deep infections or collections adjacent to loops of bowel and CT should be used for these cases • Abscesses can be extremely difficult to resolve and options for treatment include IR-guided percutaneous drainage, surgery, and antibiotics
References 1. ACR Appropriateness Criteria – Acute Nonlocalized Abdominal Pain. Available at acsearch.acr.org/docs/69467/Narrative. American College of Radiology. Accessed 19 August 2019. 2. ACR Appropriateness Criteria - Radiologic Management of Infected Fluid Collections. Available at acsearch.acr.org/docs/69345/Narrative. American College of Radiology. Accessed 19 August 2019. 3. Bell, Daniel J. and Frank Galliard, et al. “Abscess.” Radiopaedia. Available at radiopaedia.org/articles/abscess?lang=us. Accessed 19 August 2019.
RADY 401 Case Presentation William King, August 2019 Focused pati tient his
Low-grade Appendiceal Mucinous Neoplasms Marco Adly RADY 401 Case
RADY 403 Case Presentation Pulmonary Embolus in a Patient with a Left-sided
RADY 401 Case Presentation Jaslyn Pigott, MS3 May 2019 Focused patient his
H1 2019 Results 2 August t 2019 Howard Davies Chairman Ross McEwan Chief
RADY 401 Case Presentation Ed. John Lilly, MD Ms. O is a 24 yo G0 who
RADY 401 Case Presentation Ed. John Lilly, MD Ms. NT is a 16 yo female with a
RADY 401 Case Presentation Ed. John Lilly, MD 33 yo male with history of
RADY 413 Case Presentation Ed. John Lilly, MD 30 year old lactating female
RADY 403 Case Presentation Ed. John Lilly, MD 30 yo F G4P2012 at 37w admitted
CDI AND CODING ISSUES RELATED TO SEPSIS August 15, 2018 CONTINUING EDUCATION
Diabetes-Related Foot Pathology High morbidity Lifetime ulcer risk for
Arch Clin Med Case Rep 2020; 4 (1): 071-74 DOI: 10.26502/acmcr.96550168 Case
International Journal of Clinical Rheumatology Research Article Clinical
Development of Drugs for Skin Infections John H Rex, MD EFPIA - Skin
FRP Fiber Reinforced polymers Carbon Fiber Repair in the Milling industry
Original Article GCSMC J Med Sci Vol (V) No (I) January-June 2016 Study
each individual, patients with T-score -2.5 on single minutes at 37C.
ICOI DIPLOMATE ORAL EXAM Case Presentation Format May be presented on a
Diverticular Disease of the Colon EPIDEMIOLOGY Overall prevalence - 12% to
4/24/2012 th Annual 28 th 28 Annual Perinatal Perinatal Conference
Cutaneous Larva Cutaneous Larva Migrans and and Myiasis Myiasis Migrans