Triaging the acute abdomen patient in an Oncologic setting.

Transcription

1 Triaging the acute abdomen patient in an Oncologic setting. Poster No.: C-1628 Congress: ECR 2015 Type: Educational Exhibit Authors: C. V. S. R. B. Saripalli, B. Raghavan, D. Sundaram; Chennai/IN Keywords: Acute, Outcomes analysis, CT, Oncology, Gastrointestinal tract DOI: /ecr2015/C-1628 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 26

2 Learning objectives The aim of the study is to illustrate the various presentations of acute abdomen in an oncology setting and correlate it with the various management strategies. Imaging plays key role in the diagnosis of acue abdomen. MDCT plays a vital role in localizing and analyzing the cause of acute abdomen( Fig. 1 on page 3 ),thus helping us to triage the patient for appropriate management. Fig. 1: Approach to acute abdomen in oncology patients References: RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 2 of 26

3 Images for this section: Fig. 1: Approach to acute abdomen in oncology patients RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 3 of 26

4 Background Most common complaints among oncology patients who present to the emergency department are related to the gastrointestinal system and 40% of these patients complain (1) of acute abdominal pain. Diagnosis of the cause of acute abdomen in a cancer patient is complex because of the numerous etiological possibilities which can affect the management. Etiology: The causes of acute abdomen can be due to primary bowel pathologies, vacular or inflammatory pathologies. (Fig. 2 on page 6) However these causes can be ultimately related primary tumor or progressive disease, adverse effects related to treatment or causes unrelated to the underlying malignancy. Fig. 2: Causes Of Acute Abdomen in Oncology Page 4 of 26

5 References: RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Indications for surgery: Majority of the patients in an oncological setting are conservatively managed. The decision for surgical intervention in an oncological setup is complex unlike a nononcological population because of abnormal physiological responses to injury and inflammation, complications associated with previous cancer therapies, and risks due to extent of the underlying cancer. Unlike acute abdomen in general population the surgey may be curative or palliative in oncology setting and due consideration must be given to the stage and prognosis of the cancer itself (2). Role of Imaging: The approach to acute abdomen in cancer patients is shown in flow chart in (Fig. 1 on page ). With increased sophistication of computerised tomographic techniques Multi detector Computerised Tomography is advantageous in the oncological setting. With MDCT, the scan time can be decreased since a thicker section of the body can be imaged with each gantry rotation. Single breath hold images of the abdomen and pelvis are feasible, even at thin collimation. This is helpful in sick oncological patients. Localization of pathology, is quick and accurate with its coronal and sagittal reformations. Rapid assessment of tumor progression and/or metastases can also be done at the same setting, thus staging is done in single investigation. This may ultimately dictate whether a surgical approach is at all possible, and if so, whether the lesions are amenable to laparoscopic reduction. Page 5 of 26

6 Images for this section: Fig. 2: Causes Of Acute Abdomen in Oncology RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 6 of 26

7 Findings and procedure details Procedure details: In our instituion we studied of 40 patients who presented with symptoms of acute abdomen in last one and half years who were either on treatment for cancer or recently diagnosed with cancer.these patients after initial clinical and imaging evaluation were assessed with MDCT and classified in to groups according to the etiologies (obstructive, vascular and infective) and various presentations (Fig. 2 on page ). The imaging findings were correlated with the oncological status of the patient. 1. Primary tumor 2. Progressive disease 3. Treatment related complications a. Post surgical b. Chemotherapy related c. Radiotherapy related 4. Unrelated to primary malignancy. Page 7 of 26

8 Fig. 3: Distribution Of Causes Of Acute abdomen References: RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN The management startegies were correlated with the imaging findings and oncological status of the patient. In our study 60% of the patients were managed conservatively. Surgical management was opted in all the patients with perforation, malignant obstruction due to primary mass (5 out of 6 patients who had localised disease), and post operative adhesions (4 out of 11 patients who didnt have diffuse disease but presented with recurrent episodes of intestinal obstruction). Page 8 of 26

9 Fig. 4: Management in various pathologies in acute abdomen References: RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Findings: I.PRIMARY TUMOR A.Primary bowel mass presenting as perforation: (Fig. 5 on page 15, Fig. 6 on page 15 ) Perforation due to bowel mass can be due to erosive tumors, tumors associated with bowel ischemia or increased intraluminal pressure from long-standing obstruction leading to weakening and rupture of the bowel wall. Colorectal carcinomas (2.5%-10% of all cases) and gastrointestinal lymphomas are the common malignancies that can undergo spontaneous perforation. (3) Page 9 of 26

10 Risk of perforation increases after systemic chemotherapy in lymphoma. B.Primary bowel mass causing bowel obstruction: (Fig. 7 on page 16) Primary bowel mass may present as (i)malignant intussception: Neoplasms account for about 65% of intussusceptions in adults. Adult small bowel intussusception are usually by benign neoplasms and, intussusceptions of the large intestine are by malignant neoplasm. Presence of fat within the intussusception suggests benign pathology. Adenocarcinoma of the colon is the most common malignant neoplasm associated with colonic intussusception. (ii)intestinal obstruction: Role of imaging is to demonstrate if it is partial or complete. Treatment options for partial and complete intestinal obstruction due to primary bowel malignancy are different. MDCT precisely diagnoses the site, level and extent of the obstruction and since we study transit of oral contrast in sectional imaging we can diagnose partial/complete obstruction without waiting for delayed images. All the 3 patients who presented with perforation were managed surgically, 6 out of 7 patients who had obstruction had laparotomy, 1 patient who had obstruction was managed conservatively in view of the extensive disease at the time of presentation. Management of acute abdomen due to primary mass is usually surgical. II.PROGRESSIVE TUMOR Progressive disease causing intestinal obstruction: (Fig. 8 on page 17) Disease progression can cause intestinal obstruction either by serosal deposits or due to infiltration from the adjacent organs. Serosal deposits may cause small or large bowel obstruction. Metastatic serosal deposit from melanoma and carcinoma breast, ovary responsible for small bowel obstruction. Page 10 of 26

11 Direct subperitoneal spread of tumor can also result in colonic obstruction (extension of pancreatic carcinoma along the transverse mesocolon with obstruction of the transverse colon). All the 7 patients with progressive disease who presented with intestinal obstruction were managed conservatively. Conservative management was the treatment of choice in patients who presented with acute abdomen with progressive disease. III.TREATMENT RELATED COMPLICATIONS: A.Post surgical complications: (Fig. 9 on page 18) (i)intestinal obstruction due to post surgical adhesions: Most common cause of small bowel obstruction in post operative patients is adhesion(>60%). Diagnosis of small bowel obstruction due to adhesions is made when all other causes of obstruction have been ruled out at CT. When a point of transition from dilated small bowel to normal-caliber bowel without apparent cause is identified, adhesions are the presumed cause. Post operative onco patients with CT findings suggestive of adhesions should be evaluated with PET-CT and delayed scans (for persistent uptake) to rule out the minimal possibility of serosal deposit. (ii)intestinal obstruction due to parastomal hernias: Parastomal hernias a form of incisional hernia, occuring adjacent to a stoma. Clinical evaluation is difficult, and herniating bowel loops through the wall defect at the stomal site can be seen in CT. In addition, because of its superior anatomic detail, MDCT may potentially detect subtle signs of strangulation, such as Mesenteric stranding Poor bowel wall enhancement Wall thickening Free air or fluid in the hernia sac Management of intestinal obstruction due to adhesions is primarily conservative with ryles tube aspiration and fluid management with surgery being reserved for recurrent intestinal obstructions. Page 11 of 26

12 B.Radiotherapy Induced Complications: (Fig. 10 on page 21) Radiation enteritis develops in patients who receive 4,500cGy or more of radiation. Suspected radiotherapy induced bowel changes must be confined to the radiation port. Factors that predispose to the development of chronic radiation enteritis Adhesions from previous abdominal surgery. Peritonitis prior to radiation therapy. Risk factors for atherosclerosis; hypertension and diabetes mellitus Chemotherapy. Early injuries or reactions usually occur within the first 3 months of therapy, usually result in mucositis. Late complications typically develop 6-36 months after completion of therapy, may develop many years later, usually result in obliterative endarteritis and ischaemic fibrosis. Management of radiotherapy induced enteritis is usually conservative, as the bowel wall is poorly vascularised and post radiation surgery is avoided. C.Chemotherapy induced Complications: (Fig. 6 on page 15, Fig. 11 on page 22,Fig. 12 on page 20 ) Complications of chemotherapy may be primary due to the adverse effects of drug itself or due to the chemotherapy induced immunosuppression. The complications range from hepatic steatosis to pneumatosis intestinalis. Asparaginase induced pancreatitis: Most common after induction phase within 3rd day - 3rd week Corticosteroids have an additive effect. Low threshold for imaging advised as symptoms are usually nonspecific and complications can be fatal. Amylase and lipase levels may be inconclusive. Ultrasound can be the initial modality and also for monitoring. CECT is used to assess the extent of necrosis and prognosis. In chemotherapy induced complications the offending drug is discontinued and alternative drugs are considered. Page 12 of 26

13 IV)INFECTIOUS PATHOLOGIES PRESENTING AS ACUTE ABDOMEN : (Fig. 12 on page 20) Onco patients are prone to have neutropenic colitis and intra abdominal abscess. Immunosuppression followed by chemotherapy or bone marrow transplantation can have suppressed constitutional symptoms. Neutropaenic colitis (Typhlitis): A necrotising inflammatory condition encountered in patients with severe neutropenia (neutrophil count< 1000 cells/mm3 ). Typically involves the caecum, sometimes extend into the ascending colon or terminal ileum. Management of infectious pathologies is usually symptomatic with appropriate antibiotics. Image guided drainage of abscesses can be done wherever feasible. (V)VASCULAR PATHOLOGIES PERSENTING AS ACUTE ABDOMEN:(Fig. 13 on page 19) Malignancy by itself or due to the chemotherapeutic drugs can result in prothrombotic state which can cause thrombosis and bowel ischemia. Direct vascular invasion of the tumor can also cause thrombosis with end organ ischemia. The presence of gas within the bowel wall, portal venous gas,and thickened bowel loops can be identified on MDCT which is the first investigation in cancer patients with high clinical suspicion for mesenteric ischemia. Other vascular causes presenting as acute abdomen are Splenic infarction Renal vein thrombosis Acute Budd-Chiari syndrome due to malignant invasion of IVC or hepatic veins from liver, kidney,adrenal and heart. Malignant invasion of graft leads to acute graft infection and entero- vascular fistula formation. Hemoperitoneum due to rupture of tumor in melanoma, RCC and HCC Management of acute abdomen due to vascular causes is usually conservative. Page 13 of 26

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15 Images for this section: Fig. 5: Primary bowel mass presenting as perforation RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 15 of 26

16 Fig. 6: Chemotherapy induced perforation in lymphoma RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 16 of 26

17 Fig. 7: Primary bowel mass causing intussusception and intestinal obstruction RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 17 of 26

18 Fig. 8: Intestinal Obstruction due to progressive disease RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 18 of 26

19 Fig. 9: Intestinal Obstruction due to post surgical complications RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 19 of 26

20 Fig. 13: Vascular Pathologies presenting as acute abdomen RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 20 of 26

21 Fig. 12: Infectious pathologies presenting as acute abdomen RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 21 of 26

22 Fig. 10: Post Radiotherapy Complications RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 22 of 26

23 Fig. 11: Asparaginase induced pancreatitis RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 23 of 26

24 Conclusion Conclusion: Majority of oncological patients with acute abdomen are managed conservatively. Triaging the patients with respect to etiology as well as oncological status with the help of MDCT helps in guiding the surgeon for effective management thereby by reducing morbidity. Fig. 14: Management approach in acute abdomen in oncology patients. References: RADIOLOGY, APOLLO SPECIALITY HOSPITAL - Chennai/IN Page 24 of 26

25 Personal information Dr.Bagyam Raghavan, Senior Consultant, Department Of Radiology, Apollo Speciality Hospital, Chennai. Dr.C. V. S. R. B. Saripalli 2nd year DNB Resident, Department Of Radiology, Apollo Speciality Hospital, Chennai. Dr. Dayala Sundaram Final Year DNB Senior Resident Department Of Radiology, Apollo Speciality Hospital, Chennai. Page 25 of 26

26 References 1.Cancer Emergencies:The Acute Abdomen, Jonathan S. Ilgen, MD, Amy L.Marr, MD Emerg Med Clin N Am 27 (2009) Acute Abdomen, Bowel/Biliary Obstruction, and Fistula; Chapter 47; Pages ; Abeloff's Clinical Oncology, 5th Edition 3.CT Findings of Colonic Complication Associated with Colon Cancer :Kim et al.korean J Radiol 2010 ; 11: Cross-sectional imaging of acute abdominal conditions in the oncologic patient, Matthew T. Heller, Vineet Khanna, Emerg Radiol (2011) 18: Contrast-enhanced multi detector CT in the diagnosis of acute abdominal pain, A. Daniel Sasson, MD, SUPPLEMENT TO APPLIED RADIOLOGY, June 2003 Page 26 of 26