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

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

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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,

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Vic Showalter MS4 December 2018

Edited by John Lilly, MD

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 30 y/o Female  RLQ abdominal pain  Duration: 1 day  Denies: nausea, vomiting, fevers,

change in stool

 No PMH or FH  Vitals: Mild Tachycardia  Physical Exam

  • Non toxic appearing
  • RLQ tenderness
  • No rebound tenderness

 Labs Ordered: CBC, BMP, UA, UPT

  • WBC: 11.8
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 Appendicitis  Gastritis  Intussusception  Ovarian torsion  Diverticulitis  Renal stone  Constipation

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Computerized Tomography

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  • Single Node
  • Fat stranding
  • Possible bowel

wall thickening Normal structures: Cecum C Small bowel SB Common Iliac artery IA Psoas muscle PM IA C SB PM

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  • Inferior to

previous section

  • Visualize cecum
  • Visualize normal

appendix

  • No signs of

inflammation Normal structures: Sacrum S External and Internal Iliac Arteries EIA IIA S IIA EIA

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SLIDE 7
  • Single node

inflammation 9mm diameter with adjacent fat stranding

  • Non affected

appendix

  • No ovarian

pathology Normal structures: Appendix Ap Ovaries/adnexa OA Ap OA OA

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One Dx! Mesenteric Adenitis

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

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 Clinical Symptoms

  • Children, adolescents, young adults
  • Uncommon over age of 20
  • +/- Fever
  • +/- Nausea and vomiting
  • Changes in stool consistency
  • RLQ pain (epigastric)
  • Rebound tenderness (present in ¼
  • f patients)

 Labs

  • CBC - elevated white count
  • CRP - elevated

 Work up other possible

pathologies first

 Diagnosis of exclusion

Helbling et al. Biomedical Research International. 2017

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 2 Types

  • Primary (no identifiable

underlying cause)

  • Secondary

▪ Systemic Inflammatory Diseases (i.e. Lupus) ▪ Malignancy ▪ HIV ▪ Tuberculosis ▪ Infectious (zoonotic: Yersinia enterocolitica) ▪ Gastritis

 Pathophysiology

  • Inflammation of mesenteric

lymph nodes

  • Not well understood

 Management

  • Primary

▪ Hydration ▪ Pain medication ▪ Self limiting

▪ 2-3 weeks normal duration ▪ 10 weeks maximum

  • Secondary: address underlying

etiology

Helbling et al. Biomedical Research International. 2017

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 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

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Sanchez et al. J Ultrasound Med. 2016

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Macari et al. American J Roentegenology. 2002

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 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

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 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

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1.

Acsearch.acr.org. (2018). Appropriateness Criteria. [online] Available at: https://acsearch.acr.org/list [Accessed Dec 7th 2018]

2.

Helbling R, Conficconi E, Wyttenbach M, Benetti C, Simonetti G, Bianchetti M, Hamitaga F, Lava S, Fossali E, Milani G. Acute Nonspecific Mesenteric Lyphadneitis More Than “No Need For Surgery. BioMed Research International. 2017 Article IS 9784565

3.

Sanchez T, Corwin M, Davoodian A, Stiein-Wexler R. Sonography of Abdominal Pain in Children: Appendicitis and Its Common

  • Mimics. J Ultrasound Med. 2016; 35:627-635

4.

Benetti C, Conficconi E, Hamitaga F, Wyttenbach M, Lava S, Milani G, Bbianchetti M, Simonetti G, Helbling R. Course of acute nonspecific mesenteric lymphadenitis: single center experience. Eur J Pediatr. (2018) 177:243-246

5.

Neuman, Mark. Causes of Acute abdominal pain in children and adolescents. UptoDate. https://www-uptodate- 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 6th 2018]

6.

Mittal MK, Dayan PS, Macias CG, et al. Performance of ultrasound in the diagnosis of appendicitis in children in a multicenter

  • cohort. Acad Emerg Med 2013; 20:697

7.

Garcia Peña BM, Mandl KD, Kraus SJ, et al. Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. JAMA 1999; 282:1041.

8.

Carroll AG, Kavanagh RG, Ni Leidhin C, Cullinan NM, Lavelle LP, Malone DE. Comparative Effectiveness of Imaging Modalities for Diagnosis and Treatment of Intussusception: A Critically Appraised Topic. Acad Radiol. 2017, May; 24 (5):521-529

9.

Hryhorczuk AL, Strouse PJ. Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception. 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.