Vic Showalter MS4 December 2018 Edited by John Lilly, MD Vitals: - PowerPoint PPT Presentation

Vic Showalter MS4 December 2018 Edited by John Lilly, MD

 Vitals: Mild Tachycardia  30 y/o Female  Physical Exam  RLQ abdominal pain  Non toxic appearing  Duration: 1 day  RLQ tenderness  Denies: nausea, vomiting, fevers,  No rebound tenderness change in stool  Labs Ordered: CBC, BMP, UA, UPT  No PMH or FH  WBC: 11.8

 Appendicitis  Gastritis  Intussusception  Ovarian torsion  Diverticulitis  Renal stone  Constipation

Computerized Tomography

SB • Single Node • Fat stranding C • Possible bowel wall thickening Normal structures: IA PM Cecum C Small bowel SB Common Iliac artery IA Psoas muscle PM

• Inferior to previous section • Visualize cecum • Visualize normal appendix • No signs of EIA IIA inflammation Normal structures: Sacrum S External and Internal Iliac Arteries EIA IIA S

• Single node inflammation 9mm diameter with adjacent fat stranding • Non affected appendix Normal structures: • No ovarian Ap Appendix Ap pathology Ovaries/adnexa OA OA OA

One Dx! Mesenteric Adenitis

 Pain Control  Hydration  One dose abx (concerns for appendicitis)  Surgery consulted  Scheduled for exploratory laparoscopy  Laparoscopy yet to be performed

 Labs  Clinical Symptoms  CBC - elevated white count  Children, adolescents, young adults  CRP - elevated  Uncommon over age of 20  +/- Fever  Work up other possible  +/- Nausea and vomiting pathologies first  Changes in stool consistency  RLQ pain (epigastric)  Diagnosis of exclusion  Rebound tenderness (present in ¼ of patients) Helbling et al. Biomedical Research International . 2017

 Pathophysiology  2 Types  Inflammation of mesenteric  Primary (no identifiable lymph nodes underlying cause)  Not well understood  Secondary  Management ▪ Systemic Inflammatory Diseases  Primary (i.e. Lupus) ▪ Hydration ▪ Malignancy ▪ Pain medication ▪ HIV ▪ Self limiting ▪ Tuberculosis ▪ 2-3 weeks normal duration ▪ Infectious (zoonotic: Yersinia ▪ 10 weeks maximum enterocolitica)  Secondary: address underlying ▪ Gastritis etiology Helbling et al. Biomedical Research International . 2017

Sanchez et al. J Ultrasound Med . 2016  Imaging recommended  US best modality  Multiple definitions ▪ 3 lymph nodes > 5mm at short axis ▪ 1 lymph node > 8mm at short axis ▪ Bowel wall thickening  Same definition for CT ▪ Fat stranding  Few adult studies mention CT  Majority of studies pediatric based

Sanchez et al. J Ultrasound Med . 2016

Macari et al. American J Roentegenology . 2002

 Poorly studied imaging efficacy for this disease process  No tested sensitivities or specificities for mesenteric adenitis  Appendicitis  Sensitivity: 98%  Specificity: 92%  Visualization rates 22-98%  Intussusception  Sensitivity: ~ 97.9%  Specificity: ~ 97.8% Mittal et al . Acad Emerg Med . 2013 Garcia Pena et al. JAMA . 1999 Carroll et al. Acad Radiol. 2017

 Radiation Exposure  ~3 mSv for CT  No exposure for US  Cost  Abdominal CT w/ contrast: ~ $512 - $5055  Abdominal US: $436 - $1404 Shrimpton et al. Br J Radiol. 2006

Acsearch.acr.org. (2018). Appropriateness Criteria. [online] Available at: https://acsearch.acr.org/list [Accessed Dec 7th 2018] 1. Helbling R, Conficconi E, Wyttenbach M, Benetti C, Simonetti G, Bianchetti M, Hamitaga F, Lava S, Fossali E, Milani G. Acute 2. Nonspecific Mesenteric Lyphadneitis More Than “No Need For Surgery. BioMed Research International . 2017 Article IS 9784565 Sanchez T, Corwin M, Davoodian A, Stiein-Wexler R. Sonography of Abdominal Pain in Children: Appendicitis and Its Common 3. Mimics. J Ultrasound Med. 2016; 35:627-635 Benetti C, Conficconi E, Hamitaga F, Wyttenbach M, Lava S, Milani G, Bbianchetti M, Simonetti G, Helbling R. Course of acute 4. nonspecific mesenteric lymphadenitis: single center experience. Eur J Pediatr. (2018) 177:243-246 Neuman, Mark. Causes of Acute abdominal pain in children and adolescents. UptoDate . https://www-uptodate- 5. com.libproxy.lib.unc.edu/contents/causes-of-acute-abdominal-pain-in-children-and- adolescents?search=mesenteric%20lymphadenitis&sectionRank=1&usage_type=default&anchor=H23&source=machineLear ning&selectedTitle=1~25&display_rank=1#H23 [Accessed Dec 6 th 2018] Mittal MK, Dayan PS, Macias CG, et al. Performance of ultrasound in the diagnosis of appendicitis in children in a multicenter 6. cohort. Acad Emerg Med 2013; 20:697 Garcia Peña BM, Mandl KD, Kraus SJ, et al. Ultrasonography and limited computed tomography in the diagnosis and 7. management of appendicitis in children. JAMA 1999; 282:1041. Carroll AG, Kavanagh RG, Ni Leidhin C, Cullinan NM, Lavelle LP, Malone DE. Comparative Effectiveness of Imaging Modalities 8. for Diagnosis and Treatment of Intussusception: A Critically Appraised Topic. Acad Radiol. 2017, May; 24 (5):521-529 Hryhorczuk AL, Strouse PJ. Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception. 9. Pediatr Radiol 2009; 39:1075. 10. Shrimpton, PC, Hillier, MC, Lewis, MA, Dunn, M. National survey of doses from CT in the UK: 2003 . Br J Radiol 2006; 79:968. 11. “Find Your Fair Price.” Healthcare Bluebook, CAREOperative, www.healthcarebluebook.com/page_SearchResults.aspx?CatID=42.