Patient data. Present illness. Past history. Initial Impression

Transcription

1 GS-ER combine meeting 報告者 :R1 王帝皓指導者 :VS 連楚明 Patient data 25 y/o man Visited at 23:22 Chief complain: abd pain since 5:00 pm Triage: III Vital signs: BT: 35.7, PR: 75, RR: 18, BP: 121/70 SpO2: 99% E4M5V6 Present illness 吃了一顆水煎包後開始痛 Periumbilical region Colicky, persist 痛到站不直 Radiated to RLQ Not radiated to back No diarrhea/ vomit, no fever Past history Healthy No alcohol use Norecreation drug use No op history NKA PE Conscious: clear, alert Head & neck: supple Chest: Clear BS, RHB ABD: soft, no guarding, no rebounding. Normoactive BS Ext: warm Initial Impression Abd pain R/O diverticulitis R/O pancreatitis R/O appendicitis

2 Orders NPO CBC/DC/PLT PT, APTT Panel 1, CRP, lipase N/S run 60ml/hr Keto 1 amp IV st Bed side echo Bed side echo Bed side echo No hydronephrosis No GB distended, no wall thicken No free air Cecum wall edema 2 hrs later Still abd pain, VAS: 7 Rebound: mild 檢驗項檢驗值目名稱 檢驗項目名稱 檢驗值 檢驗值單位 PT 10.8 second Norma l 10.6 second control INR 1.02 Ratio APTT 33.0 second Norma l control 32.8 second Glucos e GOT( AST) 檢驗值單位 最小參考值 103 mg/dl 最大參考值 U/L BUN 16 mg/dl Creatin ine 0.8 mg/dl Na 146 meq/l K 4.1 meq/l egfr Lipase 60 U/L CRP mg/dl 檢驗項目名稱 檢驗值 檢驗值單位 Hb 15.9 gm/dl WBC 14.7 x1000/u l Differen tial count Segmen ted Neutro. Lympho cyte Monocy te Eosinop hil Basophi l ****** **** Platelet % 23.2 % 5.0 % 5.9 % 0.4 % x1000/u l Do abd CT 1.right sided small intestine almostly with segmental bowel dilatation, perienteric edema and short segmental diminished bowel wall enhancement associate small amount of the ascite. There is no intramural bowel gas and no extraluminal free air. Focal area of mesentery traction to one direction with mild torsion associate bird-beak like narrowed bowel segment disclsoed at RLQ. T-colon found almostly at left and lower abdomen. Cecum found at pelvic floor. 2.no apparent focal parenchymal nodule in the liver, spleen and pancreas. 3.symmetric perfusion of both kidneys. Mild pelviectasia on right side found. 4.no apparent biliary tree nor MPD dilatation. There is no detectable hyperdense or calcified biliary stone. GB appears to be normal. Pericholecystic space is clear. CT impression Mid-gut non-rotation or malrotation with RLQ internal hernia and probability of focal strangulation.

3 Orders IV fluid Cefa NPO Consult GS On NG decompression S-S enema BID Next morning Admit to GS ward Prepare for explore laparotomy OP findings: Operator: Dr. Right paraduodenal hernia Transition zone due to herniation and adhesion of proximal ileum at paracecal area and entrance of the sac. Operation time: 80 mins. Post-op course Smooth recovery, Try diet at D4 Discharged at post op day 7 OPD F/U: doing well Discussion Internal hernia

4 Internal Hernia Hernias are of two main types, external and internal [1]. External hernias refer to prolapse of intestinal loops through a defect in the wall of the abdomen or pelvis internal hernias are defined by the protrusion of a viscus through a normal or abnormal peritoneal or mesenteric aperture within the confines of the peritoneal cavity. The orifice can be either ac- quired, such as a postsurgical, traumatic, or postinflammatory defect, or congenital, in- cluding both normal apertures. Incidence Although internal hernias have an overall incidence of less than 1%, they constitute up to 5.8% of all small-bowel obstructions, which, if left untreated, have been reported to have an overall mortality exceeding 50% if strangulation is present. Internal Hernia paraduodenal (53%), pericecal (13%), foramen of Winslow (8%), trans- mesenteric and transmesocolic (8%), inter- sigmoid (6%), and retroanastomotic (5%) (Fig. 1), with the overall incidence of internal hernias being %. Internal Hernia Fig. 1 Diagrammatic illustration shows various types of internal hernias: A = paraduodenal, B = foramen of Winslow, C = intersigmoid, D = pericecal, E = transmesenteric, and F = retroanastomotic. General Clinical Findings Clinically, internal hernias can be asymptomatic or cause significant discomfort ranging from constant vague epigastric pain to intermittent colicky periumbilical pain. Additional symptoms include nausea, vomiting (especially after a large meal), and recurrent intestinal obstruction. Symptom severity relates to the duration and reducibility of the hernia and the presence or absence of incarceration and strangulation. These symptoms may be altered or relieved by changes in patient position. General Imaging Findings on Radiography and CT General radiographic features with barium studies in- clude apparent encapsulation of distended bowel loops with an abnormal location, ar- rangement or crowding of small-bowel loops within the hernial sac, evidence of obstruction with segmental dilatation and stasis, with additional features of apparent fixation and re- versed peristalsis during fluoroscopic evaluation [1, 5] (Table1). On CT, additional findings include mesenteric vessel abnormalities, with engorgement, crowding, twisting, and stretching of these vessels commonly found and providing an important clue to the underlying diagnosis

5 Paraduodenal Hernias accounting for approximately 53% of all cases [1]. Unlike most types of internal hernias, this subtype does have a sex predilection, being found more commonly in men by a ratio of 3:1. There are two main types, left and right, with the former consisting of most (75%) cases [1, 6 8]. RadioGraphics EDUCATION EXHIBIT 997 CME FEATURE See accompanying test at /education /rg_cme.html CT of Internal Hernias 1 Nobuyuki Takeyama, M D Takehiko Gokan, M D Yoshimitsu Ohgiya, MD Shuichi Satoh, MD Takashi Hashizume, MD Kiyoshi Hataya, MD Hiroshi Kushiro, M D M akoto Nakanishi, MD M itsuo Kusano, MD Hirotsugu Munechika, MD DUODENAL FOSSA 1 superior duodenal fossa (50%), 2 inferior duodenal fossa (fossa of Treitz) (75%), 3 paraduode- nal fossa (fossa of Landzert) (2%), 4 intermesocolic fossa (fossa of Broesike), 5 mesentericoparietal fossa (fossa of Waldeyer) (1%). (Adapted and reprinted, with permission, from reference 6.) Left paraduodenal hernias Left paraduodenal hernias have an overall incidence of approximately 40% of all internal hernias. They occur when bowel pro- lapses through Landzert s fossa, an aperture present in approximately 2% of the population Landzert s fossa is located be- hind the ascending or fourth part of the duodenum and is formed by the lifting up of a peritoneal fold by the inferior mesenteric vein and ascending left colic artery as they run along the lateral side of the fossa. Fig. 2 Graphic illustration of a left paraduodenal hernia depicts loop of small bowel prolapsing (curved arrow) through Landzert s fossa, located behind inferior mesenteric vein and ascending left colic artery (straight arrow). Herniated bowel loops are therefore located lateral to fourth portion of duodenum.

6 Fig. 4 CT scans from six patients with left paraduodenal hernia. A, Axial contrast enhanced CT scan in 11 year old boy shows small bowel loops (arrows) between stomach (S) and pancreas (P). B, Axial contrast enhanced CT scan in 28 year old man shows small bowel loops (white arrow) behind pancreas (P) itself. Black arrow indicates stomach. C, Axial contrast enhanced CT scan in 36 year old man shows small bowel loops (arrows) displaying inferior mesenteric vein (arrowhead) to left. D, Coronal reconstruction of contrast enhanced CT data set in 28 year old man shows small bowel loops between transverse colon (T) and left adrenal gland (arrow). (a) Contrast enhanced CT scan of the upper abdomen shows a saclike mass of proximal jejunal loops (J). In this case, CT did not show the inferior mesenteric vein, which is a landmark for left PDH. (b) CT scan obtained 30 mm below a shows a horseshoelike configuration of collapsed jejunal loops (arrowheads) and dilated mesenteric vessels (arrow) between the pancreas (P) and stomach (S) without mass effect. Right Paraduodenal Hernia Right paraduodenal hernias Right paraduodenal hernias have an over- all incidence of approximately 13% and occur when bowel herniates through Waldeyer s fossa (representing a defect in the first part of the jejunal mesentery), be- hind the superior mesenteric artery and inferior to the transverse or third portion of the duodenum. In these situations, the herniated contents are located in the right half of the transverse mesocolon and behind the ascending mesocolon. This type of her- nia occurs more frequently in the setting of nonrotated small bowel [6, 8]. When com- pared with the left paraduodenal hernias, those on the right are usually larger and are more often fixed [5]. Because right- sided paraduodenal hernias are thought to be congenital, related to abnormalities of embryologic midgut rotation, there may be additional clues such as small-bowel nonro- tation, as evidenced by the superior mesen- teric vein occupying a more ventral and left- ward position and the absence of a normal horizontal duodenum [5, 8, 9]. The cecum, however, remains in its normal position. Vascular findings include jejunal branches of the superior mesenteric artery and superior mesenteric vein looping posteriorly and to the right of Fig. 5 Graphic illustration of the parent vessel to supply right the paraduodenal herniated loops shows loop of small bowel prolapsing (curved arrow) through Waldeyer s fossa, behind superior mesenteric artery (straight arrow) and inferior to third portion of duodenum (asterisk).

7 Pericecal hernia foramen of Winslow hernia Intersigmoid hernia, transmesocolon

8 Embryonic anomaly A right paraduodenal hernia is formed when the prearterial limb fails to rotate around the superior mesenteric artery (SMA). The prearterial segment is the portion cephalic to the vitellomesenteric duct and comprises the distal duodenum and the entire small bowel to the distal ileum. Therefore, a portion of the small bowel remains to the right of the SMA. The result is a hernia orifice that is always to the right of the midline and usually faces medially and slightly downward. The mesentery of the ascending colon and a portion of the transverse colon make up the anterior wall of the sac, while the SMA and ileocolic artery lie in the free edge of the sac Case: A 41-year-old male patient, postprandial nausea, vomiting, abdominal pain and distension, which aggravated during the last 3 months, importantly affecting oral intake. CT scan an encapsulated cluster of small bowel loops occupying mainly the right upper quadrant, lateral to the duodenum, with the transverse colon located inferiorly. laparotomy; a large sac containing dilated small bowel loops Image OP finding A At abdominal inspection, a sac containing dilated small bowel loops lateral to the duodenum, displacing the colon inferiorly, was seen. B Dilated small bowel loops protruding through the fossa of Waldeyer. The superior mesenteric vessels are identified anteriorly. Thanks for your attension