54æ­²å¥³æ€§è ¹ç—›6個月 - 台中榮民總醫院

Case Challenge台屲 中 榮 民岙 總 醫 院肝 膽 胃 腸 科 張 崇 信 醫 師

學 習 重 點慢 性 腹 痛

Personal Profile姓 名峮 : 黃 X 尾性 別 : 女 年 齡 :64: 病 歷 號 :22XXX48A:居 住 地峸 : 苗 栗 縣 通 霄 鎮

Chief complaint Intermittent epigastric pain for sixmonths.

Abdominal pain - Location Epigastric pain Epigastric area 有 哪 些 器 官 ?Intermittent epigastric pain for six months.

Abdominal pain - Quality Dull and intermittent pain. Duration: 3-636 hours. 哪 些 器 官 的 哪 些 疾 病 會 這 樣 表 現 ?Intermittent epigastric pain for six months.

Abdominal pain - Quantity Pain for 6 months. Frequency: Monthly → Weekly → Daily prior toadmission 如崇 何 定 義 急 性 或 慢 性 腹 痛 ? 哪 些 疾 病 會 慢 性 腹 痛 ?

Vascular Inflammatory Trauma/Toxin Autoimmune Metabolic Idiopathic Neoplasm Substances abuse Congenital慢 性 腹 痛

慢 性 腹 痛 (organic) Vascular Celiac a. syndrome, mesenteric ischemia,SMA syndrome… Inflammatory IBD, PID, chronic pancreatitis Metabolic DM neuropathy, Porphyria…

慢 性 腹 痛 (organic) Autoimmine PSC, Eosinophilic gastroenteritis Others adhesions, endometriosis, gallstones, pepticulcer disease, lactose intolerance, intestinalmalrotation or obstruction…

慢 性 腹 痛 (functional) Biliary pain (Sphincter of Oddi dysfunction) Functional abdominal pain syndrome Functional (non-ulcer) dyspepsia Gastroparesis Irritable bowel syndrome Levator ani syndrome

考 題 一 下 列峚 哪 些 以层 急 性 腹 痛 表 現 之 疾 病 , 比尬 較 少以层 慢 性 腹 痛 來 表 現 ?A) AppendicitisB) Intestinal obstructionC) PorphyriaD) PancreatitisE) Gastroenteritis

考 題 二 下 列峚 哪 些 慢 性 腹 痛 的 疾 病 , 不 屬 於Functional GI disorders?A) Functional dyspepsiaB) Sphincter of Oddi dysfunctionC) Irritable bowel syndromeD) Inflammatory bowel diseaseE) Gastroparesis

Abdominal pain - Onset Insidious onset 下 列峚 哪 種 疾 病 不 會 以层 insidious onset 表 現 ?A) Aortic dissectionB) Peptic ulcer diseaseC) PancreatitisD) Intestinal obstructionE) Mesenteric ischemia

Precipitating and Exacerbating Food intake. Pain exacerbated at midnight.

Abdominal pain - Relieving Fasting. 哪 個 疾 病 不 會 這 樣 表 現 ?A) Gastric ulcerB) CholecystitisC) PancreatitisD) DuodenitisE) Intestinal obstruction

Accompanying Symptoms Mild nausea. 有 哪 些 Negative Findings 很 重 要 ? No radiation to back or shoulders.

Negative Findings Denied fever, weight loss, heartburn, acidregurgitation, cold sweats, chest pain,shortness of breath, bowel habit change,tarry or bloody stool passage.

考 題 三 一 位 65 歲 男 性 , 來 到 您 的 門 診 , 抱 怨 腹 痛一 年 多峿 , 伴 隨 體 重 減 輕 、 食 慾 差 、 發 燒 、盜 汗 , 而 且尼 偶 爾 半屜 夜 會 痛 醒 , 請 問 下 列峚 哪個 理 由岩 最 不 能 支尟 持 這 個 病 人 有 個 嚴 重 的 慢性 疾 病 正岗 在峹 惡 化 ?A) 65 歲 B) 體 重 減 輕 C) 食 慾 降 低 (D) 發 燒

Personal history Smoking : denied Alcohol : denied No Diabetes mellitus, no Hypertension Operation history : Hysterectomy

Physical examination Vital signs: T/P/R 36.7/ 63 /16 BP:118/64 mmHg Body weight:54.9kg height:154cm Skin : normal skin turgor , no jaundice HEENTEyes: Conjunctiva: pink , Sclera: anicteric Chest : no rales , no rhonchi , no wheezing Heart : Regular heart beats , no murmur Extremities : no pitting edema , normal peripheralpulse

Physical examination Abdomen Inspection: no distension, no hernia, operation scarover lower abdomen Auscultation: normal bowel sound Palpation: Soft, mild A2 tenderness , norebounding pain , no muscle guarding , no palpablemass Percussion: no shifting dullness , no centraltympanic

Impressions ? Intra-abdominal or Extra-abdominal ? GI tract or hepatobiliary or pancreatic ? 想 再峘 做 哪 些 檢 查 ? 預 期 有 什 麼 發 現 ?

考 題 四屶 一 位 64 歲 女 性 , 抱 怨 有 陣 發 性 的 上 腹 悶 痛 六 個 月尦, 最 近 頻 率 及 疼 痛 程 度 加展 劇 , 請 問 下 列峚 何 者 正岗 確 ?A) 若 抽 血 Bil-T 2.0 mg/dL, 可屣 診 斷 是 膽 道 方尣 面 的 疾 病B) 若 抽 血 Lipase 100 U/L, 可屣 診 斷 是 胰 臟 方尣 面 的 疾 病C) 若 抽 血 HgB 14 g/dL, 可屣 排 除 是 腸 胃 道 方尣 面 的 疾 病D) 若 抽 血 CA 19-9 上 昇 達 80 U/mL, 可屣 診 斷 胰 臟 癌E) 以层 上 皆 非

重 點 針 對 慢 性 腹 痛 的 病 人 , 抽 血 或 許 能 夠 提 供臨 床 醫 師 某 些 訊 息 , 但 是 漫 無 目岰 的 的 抽 血, 不 但 花 費 昂 貴 , 還 可屣 能 誤 判 疾 病 ! 針 對 慢 性 腹 痛 的 病 人 , 檢 驗 的 目岰 的 在峹 於 配合峯 病 史屰 詢 問 及 身 體 檢 查 , 以层 提 供 臨 床 醫 師正岗 確 的 訊 息 。

Laboratory DataCEA

Abdominal CT

EGD scopyDuodenal submucosal tumor, third portion

Scan for Merckel’s diverticulum

Operation finding Redundant mesentarywith volvulus of smallintestine No ischemia changeAfter mobilize all small intestine,mesentary root was plicated toretroperitoneum A diverticulum, , 2x2 cmin size (terminal ileum)

Final Diagnosis Chronic volvulus of small intestine,redundant mesentary related

DiscussionVolvulus of small intestine

An infrequent cause of small-bowel obstructionVolvulus of the Small IntestineAnn. Surg. * November 1988

MechanismSmall intestinal volvulus Twisting around the main trunksof the superior mesenteric vessels Torsion of a small bowel segment whoseproximal and distal ends are closelyopposed (closed-loop)loop)Small bowel volvulus among adults.J Gastroenterol Hepatol 2005;20:1906–12.

Types of small intestinal volvulus Primary volvulus:without any apparent intrinsic anatomicalanomalies Secondary volvulus:with anatomical abnormality

Primary volvulus Longer mesenteric length, shortermesenteric base Race: difference of small-bowel lengthsRussian : averaged 6.9 mGerman : averaged 5.79 m Large high-fiber meals after prolongedfasting leads to forceful bowel peristalsis Abrupt transit of a large bulky meal into theproximal jejunumVolvulus of the Small IntestineAnn. Surg. * November 1988

Secondary volvulus More common than primary volvulus With anatomical abnormality Midgut malrotation Adhesions Mesenteric or omental defects Intestinal diverticulum Tumor PregnancyVolvulus of the Small IntestineAnn. Surg. * November 1988

Clinical Presentation A rare cause of surgical emergency Most cases were medical emergency Long-term and intermittent symptoms chronic twisting of the small bowel andincomplete intestinal obstructionVolvulus of the Small IntestineAnn. Surg. * November 1988

Clinical Presentation Clinical presentations : Abdominal pain: : 100% (non-specific, +/- peritoneal signs) Nausea and vomiting: 91% Abdominal distention :74% Obstipation:58% Tachycardia :56% Fever: 14% Laboratory abnormality : Leukocytosis: 73% Left shift :68% Mean amylase level : 152 U/L (normal being 35-115)Volvulus of the Small IntestineAnn. Surg. * November 1988

Diagnosis_x filmRole of plain film Flat and upright abdominal roentgenogram : Findings consistent with the small bowelobstruction : 77% Findings compatible with closed-loop loop obstruction :only 16% Difficulty diagnosed by plain filmVolvulus of the Small IntestineAnn. Surg. * November 1988

Diagnosis_CTCT whirl sign Diagnostic tool of choice Whirl sign:soft-tissue tissue mass with swirling strands of softtissue and fat attenuationFisher JK. Computed tomographic diagnosis of volvulus inintestinal malrotation. Radiology 1981; 140:145–6 Presence of whirl sign strong predictor for theneed for prompt surgical interventionUtility of CT whirl sign in guiding management of small-bowelobstruction. AJR Am J Roentgenol 2008; 191:743–7.

Diagnosis_CTN ENGL J MED 365;4 July 28, 2011

Does the CT Whirl Sign Really PredictSmall Bowel Volvulus? Experienced radiologist can detect most casesof volvulus by the ”whirl sign” But positive predictive value is quite limited Most patients manifesting this sign on CTwill not have small bowel volvulusDiagnosis_CTJournal of Computer Assisted Tomography:January/February 2006 - Volume 30 - Issue 1 - pp 25-32

Diagnosis_CT Patient with CT whirl sign is 25.3 times to have SBOthan without the sign Whirl sign in assessment of the treatment options forclinical and radiologic signs of SBO.Utility of CT whirl sign in guiding management of small-bowelobstruction. AJR Am J Roentgenol 2008; 191:743–7.

Jejunoileal Diverticulosis Surgeons see often in clinical practice Rarely cause of small bowel volvulus Small bowel diverticulum induce volvulus Tumor-like effecttriggers the small bowel to twist and hampersits repositioning Inflammation small bowel adhesionsAcquired Jejunoileal Diverticulosis and Its Complications: A Review of the LiteratureThe American Surgeon, Volume 74, Number 9, September 2008 , pp. 849-854(6)

Treatment & Prognosis 49% patients had vascular compromise atlaparotomy and required resection Overall perioperative mortality : 12.3 % In ischemic bowel group: 21.4% Small intestine volvulus must be considered inSBO patient Early operative intervention to preventvascular compromise

Take Home Messages Volvulus of the small intestine Infrequent cause of small-bowel obstruction Must be considered in small-bowel obstructionpatient Early operative intervention to prevent vascularcompromise Important role for the CT whirl sign in assessment ofthe treatment options for patients with clinical andradiologic signs of SBO

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