七院聯合 CPC 93 年 11 月 03 日

鄧景升醫師 /李春銘主治

三軍總醫院 小兒部

Chief complaints

• Progressive abdominal pain, occasional vomiting, diarrhea and intermittent high fever for six days

Present illness

• A two- year- old boy was in good condition without any complaint of abdominal symptoms before presentation.

• He was referred to our pediatric clinic with a six- day history of progressive abdominal pain and intermittent high fever.

• Vomiting and diarrhea were occasionally accompanied with abdominal pain.

• Appetite decreased.

Physical examinations

• BT: 39’C

• Abdomen: palpable mass on RUQ of abdomen

Laboratory data

Initial laboratory data• WBC: 16.2 X 109/ l • Neutrophil: 83%• ESR: 82 mm/h• CRP: 8.8 mg/dl• PPD skin test: negative• Biochemical data: normal range• Blood culture: pending result• Stool culture: pending result

Hospital course

• After admission, KUB and abdominal ultrasound were arranged.

• The abdominal ultrasound revealed a target lesion on the RUQ of the abdomen the presumptive diagnosis of intussusception was made at that time.

• Barium enema reduction was attempted but failed to find intussusceptum.

• CT of abdomen was performed.• The patient was placed at bowel rest, and intra

venous fluid were administration. • A blood culture and stool culture were obtaine

d, and empirical antibiotic therapy was initiated

Image studies

• KUB: non specific gas pattern

• Abdominal sonography: a target lesion on the RUQ of the abdomen

• Barium enema: A radiopaque filling defect with moth- eaten margin in the ascending colon near the hepatic flexure region.

Image studies

• CT of the abdomen: circumferential thickening of the intestinal wall in the ascending colon. The length of the thickened segment was about 7 cm, and the wall thickenness was about 2 cm

Questions to be asked

Questions: (1)

• What was the pattern of abdominal pain? Location ? physical examination?• Vital sign?, BP, RR, PR?• Weight loss ?• Other signs of physical examination? Chest ?abdomen ? Bowel sound? Rigidity? Soft ? Locate the site of maximal pain? Tenderness? Pattern of palpable mass ?, etc.• Was there any other enlarged lymph nodes on physical exami

nation ?History?• Did he have history of foreign travel ? Did he live with froeign s

ervant?• Was there family history of cancer ?• Have the patient drunk unpasteurized milk?• Did he have history of contact with a case of tuberculosis, a pa

rent ? or other family ?

Questions: (2)

Lab• Stool routine? Stool pattern ? Bloody stool ? Examinatio

n of stool specimens showed ova or parasites?• CBC-H, LDH, uric acid level ?• Chest X-ray ?• Was there any other findings on CT and barium enema ?

Another abnormal finding on other sites ? skip lesions ? fissures, sinus tracts, fistulas ? Hepatosplenomegaly?

• Did CT scanning show any other lymphadenopathy in this patient ?

• colonoscopic examination ?

• What are the patient’s problems ??

Major Problems

• Palpable mass on RUQ of abdomen

• Abdominal ultrasound revealed a target lesion on the RUQ

• Barium enema: a radiopaque filling defect with moth- eaten margin in the ascending colon near the hepatic flexure region.

• CT of the abdomen: circumferential thickening of the intestinal wall in the ascending colon.

• Abdominal pain• High fever• Vomiting• Diarrhea • Leucocytosis• Elevation of ESR and C

RP

Minor Problems

Abdmonial mass Target lesion

Filling defect Thickened bowel wall

high fever

location

Target lesion

• A target lesion at the ultrasound scan indicating thickened bowel wall

• On ultrasonography encircling thickening of the colonic wall (target sign).

Journal of Korean Medical Science. 15(4):371-9, 2000 Aug.

Target sign Gastroenterology Clinics

Volume 31 • Number 3 • September 2002

• Neoplasms bowel wall thickening target sign or “pseudokidney” sign

• Focal inflammatory or ischemic masses.

• Perforating diverticulitis

• Ischemic colitis : "target lesion"

filling defect

• A lesion protruding into the lumen appear as a radiolucent filling defect in the barium pool

• Mass lesion

• Ischemic colitis

• Amoebiasis– amoeboma

CT Diagnosis of the Abnormal Bowel Wall

Radiographics. 2002;22:1093-1107 Thickened bowel wallidiopathic inflammatory bowel

diseases, infectious diseases, radiation damage. malignancy.

Causes of large-bowel strictures

Physiological • Spasm • Distended bladderMalignant  Annular carcinoma  Scirrhous carcinoma  LymphomaDiverticular disease  Muscle thickening  Pericolic abscess  Superimposed malignancyIschaemiaRadiation colitis

Inflammatory bowel disease  Ulcerative colitis  Crohn’s disease  Tuberculosis  Lymphogranuloma venereum

  AmoebiasisExtrinsic disease  Intra-abdominal masses  Metastatic carcinoma  Endometriosis  Pelvic lipomatosis  Cholecystitis  PancreatitisMiscellaneous  Postoperative anastomosis  Trauma  Hirschsprung’s disease

Malignant abdominal masses (nonneonatal)

• Hepatic: Hepatoblastoma Hepatocellular carcinomaRhabdomyosa

rcoma (rare)Angiosarcoma (ver

y rare)• Renal Wilms' tumor Renal cell carcinoma(rar

e) Lymphoma (very rare)• Adrenal Neuroblastoma  Adrenal cortical carcinom

a (rare)

• Gastrointestinal Lymphoma Carcinoid (appendix) Teratoma Carcinoma (very rare)• Lymphatic Lymphoma• Other Teratoma Neuroblastoma, sympathetic chain Sarcoma Pancreatoblastoma (very

rare)

Teratoma• The sacrococcygeal region: most site.• most commonly in infants, at birth, • femalesCarcinoid Tumors• usually occur in the appendix in children• outside the appendix (ileojejunum, colon) commonly me

tastasize• carcinoid syndrome episodic intestinal hypermotility

and diarrhea, vasomotor disturbances (flushing) (75% to 90%) , bronchoconstriction (wheezing) (25%), and right-sided heart failure

• Barium enema: single or multiple filling defects in the distended ileum

• Carcinoid tumors rarely occur in the large intestine X

LYMPHOGRANULOMA VENEREUM

• a systemic sexually transmitted disease

• Chlamydia trachomatis causes lymphogranuloma venereum. A chronic proctitis is complicated by fistula formation, extensive fibrosis, and eventual stricture formation.X

CT OF THE COLON Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed

• Three basic patterns have been described in benign disease:

(i) a homogeneous ring of bowel

wall >4 mm thick; (ii) a double halo with alternating

layers of density; (iii) target sign

Carcinoma

• Diagnosis: family history, endoscopic findings, gastrointestinal bleeding, or obstruction.

• Symptoms are nonspecific abdominal pain, an abdominal mass

• carcinoma does not follow a circumferential pattern

• Rare in children, in early adulthood• Scirrhous carcinoma may infiltrate diffusely t

o present as a relatively smooth stricture. This type of tumour is much more likely to be metastatic from the stomach or breast than a primary lesion

X

Abdmonial mass Target lesion

Filling defect Thickened bowel wall

Amebic colitis with amebomaInfectious colitis (parasitic, viral)Intestinal tuberculosisPericolic abscessInflammatory bowel disease(ulcerative colitis and Crohn’s disease )LymphomaIschemic colitis

High fever

colon

PPD skin test(Gershon: Krugman's Infectious Diseases of Children, 11th ed )

• A negative tuberculin skin test never rules out tuberculosis in a child.

• The most common causes of false-negative : incubation of viral infections

incubation of bacterial infections; overwhelming tuberculosis;

recent administration of live viral vaccines; severe malnutrition;

diseases and drugs causing anergy; extremes of age (newborns and the elderly) • False-negative TST : severe tuberculosis dise

ase soon after infection, those with immunosuppressive illnesses, malnutrition, or other severe infections.

(The Lancet Infectious Diseases Volume 3 • Number 10 • October 2003)

The Lancet Infectious Diseases Volume 3 • Number 10 • October 2003

• Extra-pulmonary tuberculosis disease is more common in children than adults, 25% of infants and young children less than 4 years of age

• But extra-pulmonary manifestations of tuberculosis, such as gastrointestinal or renal, are rare in children because of long incubation periods required following haematogenous dissemination to manifest as disease.

• The rate of false-negative TST in children with tuberculosis who are infected with HIV, is unknown, but it is certainly higher than 10% and is dependent on the degree of immunosuppression (ie, CD4 counts).

Intestinal tuberculosis

• pain, diarrhea or constipation, and weight loss with low-grade fever.

• primary bovine origin from drinking unpasteurized milk, the chest radiograph being normal. Question ?

• Ulcerative, hypertrophic or mixed forms are described.

• The ulcers tend to be large and circumferential with a shaggy edge,

• The hypertrophic form presents with an inflammatory mass and stenosis of the bowel lumen.

• palpable mass may be noted • commonest in the ileocaecal region, but may b

e seen in any part of the gastrointestinal tract

Intestinal tuberculosis

• a conical caecum with a patulous ileocaecal valve and a dilated terminal ileum

• transverse ulceration, ulcerated stricture sharply demarcated from normal bowel.

• Utrasound and CT : ascites, peritoneal involvement, and lymphadenopathy.

• Caseous lymph nodes with a hypoechoic centre on ultrasound, or peripheral enhancement on CT, with ascites and a thickened bowel wall are highly suggestive of tuberculosis.

• caseous epithelioid granulomas (CGs) are characteristic of tuberculosis.

Intestinal tuberculosis

• The diagnosis of extrapulmonary TB: collecting specimens for AFB stain and culture and sometimes for pathologic diagnosis.

• PCR: rapid diagnosis of tuberculosis. • PCR does not seem to be markedly sen

sitive for intestinal tuberculosis. Kim et al. found that the PCR was positive in only 30% of fresh biopsy specimens.

LYMPHOMA

• Usual < 3y/o• Lymphoma is the most common malignancy of

the gastrointestinal tract in children • Primary lymphoma of the colon is rare and no

n-Hodgkin’s in type. • stomach, distal ileum, cecum, or appendix and

may present as crampy abdominal pain, vomiting, distention, or a palpable abdominal mass.

• Mild fever.• The caecum or rectum are usually involved,

as these sites contain the most lymphoid tissue.

• The most common location was ileum

LYMPHOMA

• A large polypoid mass or annular lesion is typical

• Annular infiltration involving a long segment of >5 cm, with deep fissuring, cavitation, and a large extraluminal component, are features that suggest lymphoma.

X

Diverticular disease

• Diverticular disease is recognized radiologically from its two main components — the muscular abnormality and the diverticula.

• commonest in sigmoid lesions, rare in caecal lesions

• there is left-sided abdominal pain, tenderness, and some fever.

• The presence of diverticular disease : thickening of the muscle wall, and the presence of extramural gas bubbles or pockets of fluid within the diverticula. X

• Diverticular disease is a common abnormality in the elderly X

• interdigitating folds

Pericolic abscess • Perforation of a diverticulum an inflammator

y reaction in and around the wall of the colon, segmental narrowing

• Plain radiographs : localized ileus, a soft-tissue mass or, rarely, gas within the abscess.

• A water-soluble contrast enema: tracking from a ruptured diverticulum

• CT: wall thickening >4 mm of homogeneous density, and the presence of gas or contrast medium in the diverticula outpouches.

• fine stranding, a fluid collection with gas bubbles or a fluid level is diagnostic of an abscess.

• the ‘saw-tooth’ pattern ( fibrosis), which may be ‘draped’ around the site of the abscess.

Inflammatory bowel diseases

• onset at 15–25 yr of age and a second smaller peak at 50–80 yr of age. X

• Diarrhoea, fever and malaise are common to both.

• Abdominal pain and a tender mass are more typical of Crohn’s disease,

• chronic diarrhea of greater than 4 weeks' duration.

Ulcerative colitis Radiographic imaging of inflammatory bowel disease

Gastroenterology Clinics Volume 31 • Number 1 • March 2002

Double- contrast barium enema • fill with barium creating the granular --typical of ulcerativ

e colitis--X• Deeper ulcers collar-button ulcers– X• rectal bleeding -- ulcerative colitis In advanced disease • ulcerative colitis is characterized by a pancolitis with diff

use ulceration, or absent haustral folds, thumbprinting, and narrowing or shortening of the colon, most commonly in the rectosigmoid

Computed tomography • CT: mural thickening • the mean wall thickness is 8 mm, (normal colon is only 2 to 3 mm) • inhomogeneous enhancement of the colonic wall • This enhancement results in a classic target or double

halo sign

Crohn's disease • a chronic idiopathic granulomatous process ch

aracterized by transmural inflammation of the bowel, often associated with the development of fissures, sinus tracts, fistulas, and abscesses question ?

• Large anal skin tags (1–3 cm diameter) or perianal fistulas question?

• discontinuous skip lesions between areas of uninvolved bowel question ?

• most terminal ileum and proximal colon, isolated colonic disease in 20% to 27%

• may involve the gastrointestinal tract anywhere from the mouth to the anus

• chronic phase: circumferential thickening of the bowel wall, irreversible strictures in the small bowel or colon

Crohn's disease Barium studies

• the small bowel is involved in up to 80% of cases question?

• The earliest radiographic findings of Crohn's disease in the small bowel or colon are aphthous ulcers (collec

tions of barium surrounded by radiolucent halos)

• development of a cobblestone most commonly occurs in the small bowel .

Crohn's disease Computed tomography

• the most common : mural thickening

• Average wall thickness of 11 to 13 mm in the small bowel or colon

• Mural thickening is most common in the terminal ileum: thickness of 2 cm

• fistulas and sinus tracts 20% to 40% of cases

• Colonoscopy with biopsy in establishing a diagnosis.

ISCHAEMIC COLITIS

• the systemic manifestations of cardiac arrhythmia, myocardial infarction, and congestive heart failure

• abdominal pain and rectal bleeding of sudden onset.

• The mucosa oedema thumbprinting • mosaic’ pattern• The splenic flexure and the descending colon

are the commonest sites (watershed between the superio

r and inferior mesenteric arteries). X• The rectum and ascending colon are rarely inv

olved• Ischaemia is usually segmental, involving abou

t a 19-cm length.

Mosaic pattern in early ischaemic colitis Thumbprinting

Amebic colitis

• Amebic colitis affects all age groups, but its incidence is strikingly high in children 1–5 yr of age.

• a granular mucosa • The radiological features of invasive amoebiasi

s include a segmental or diffuse colitis, with a granular or ulcerated mucosa.

• Aphthoid ulceration may be seen, and amoeboma formation occurs in about 10% of cases.

• inflammatory granulation masses cause an irregular stricture

• luminal narrowing on a barium-enema examination ameboma.

• Tender, palpable, abdominal mass.

Amebic colitis

• they are often multiple and are usually found at the flexures and the caecum.

• Ameboma results from the formation of annular colonic granulation tissue at a single site or multiple sites, usually in the cecum or ascending colon. An ameboma may mimic carcinoma of the colon

Amebic colitis

• history of cramping abdominal pain, weight loss, and watery or bloody diarrhea.

• Infection with Entamoeba histolytica may be asymptomatic or may cause dysentery

• The insidious onset and variable signs and symptoms make diagnosis difficult, with fever and grossly bloody stool absent in most cases.

luminal narrowing (arrow) on a barium-enema examination in a patient with ameboma.

INFECTIOUS COLITIS

• Salmonella, Shigella and Campylobacter may all present with a localized or diffuse colitis, with a granular or ulcerated mucosa.

• marked ileus • profuse, watery diarrhea, rectal

bleeding, and edematous mucosa in the rectum

PSEUDOMEMBRANOUS (ANTIBIOTIC-

ASSOCIATED) COLITIS

• Broad-spectrum antibiotics or chemotherapy may predispose to an overgrowth of the Gram-positive Clostridium difficile

• diarrhoea, pyrexia, and leukocytosis. • Plain radiographs may show a generalized ileu

s. • CT and ultrasound may detect ascites and a th

ickened colonic wall. • Nodular haustration • stool specimen for the C. difficile toxin

VIRAL COLITIS

• ileocecal area, in immunocompetent persons. • Cytomegalovirus (CMV) causes a vasculitis wit

h a thick wall, lymphadenopathy and large ulcers that may bleed, and is typically ileocolic in distribution X

• Tissue staining for cytomegalovirus• CT will show a thickened bowel wall, mesent

eric lymphadenopathy, and often ascites. • The herpes simplex virus is associated with a

proctitis and multiple more superficial ulcers. X

PARASITIC COLITIS

• In trichuriasis ( 鞭蟲病 )small coiled worms may be seen on the mucosal surface.X

• Strongyloides stercoralis may simulate ulcerative colitis. X

• In Chagas’ disease a megacolon results from the neurotoxic effect of the protozoon Trypanosoma cruzi.

• In schistosomiasis ova are deposited in the submucosa of the large bowel. The inflammatory response results in the formation of numerous polyps. Fibrosis may later cause stricture formation and calcification may be visible in the bowel wall.X

Impression

• Amebic colitis with ameboma(Most favored)

• Intestinal tuberculosis• Crohn's disease

Diagnostic procedure

• Stool routine leukocye, or identifying cysts or motile trophozoites on a saline wet mount of a stool specimen.

• The diagnosis of extrapulmonary TB depends on collecting specimens for AFB stain and culture and sometimes for pathologic diagnosis.

• Endoscopy and biopsies

Diagnostic procedure

Therapy Amebic colitis

• Invasive amebiasis of the intestine, liver, or other organs requires the use of metronidazole (30–50 mg/kg/24 hr divided tid PO for 10 days; maximum: 500–750 mg/dose), a tissue amebicidal drug.

• The recommended regimen for treating asymptomatic cyst carriers is iodoquinol (30–40mg/kg/24hr divided tid PO for 20 days; maximum: 650mg/dose). Paromomycin, a nonabsorbable aminoglycoside, is an alternative.