Ileocecal TB.pptx

Ileocecal TB

1. A Case of A 35 years m ale with Lump in the Right Iliac Fossa Presented by Dr. Md. Redwan Ahsanullah Honorary Medical Officer Unit II, Department of Surgery

2. Particulars of the patient Name: Md. Aminullah Bablu Age: 35yrs Sex: Male Religion: Islam Marital status : Married Occupation: House painter

3. Particulars of the patient (contd.) Present address: Dakkhin Pirerbag , Amtola , Mirpur-2, Dhaka Permanent address: Village: Podua ; PO: Korombaksha ; Upazilla : Kabirhat ; District: Noakhali

4. Particulars of the patient (contd.) Date and time of admission: 10:00am on 11 July 2016 Date and time of examination: 11:00am on 11 July 2016

5. Chief complaints Fever for 5 months Lump in the right side of lower abdomen for 2 months Pain and distension o f the abdomen for 2 months

6. History of presenting illness According to the statement of the patient, he was reasonably well 5 months back. Then he developed a fever, which was low grade, intermittent , rising at evenings, associated with night sweats, not associated with chills and rigors, relieved by antipyretics , and was not recorded . He also noticed a lump , 2 months

7. History of presenting illness (contd.) back, in the right side of his lower abdomen which was initially small but gradually increasing in size. He also complained of pain in the abdomen for the same duration , which was diffuse, of moderate to severe intensity, cramping in nature, intermittent, and was not associated with any radiation or shifting.

8. History of presenting illness (contd.) The pain was associated with distension and vomiting , which was not projectile, not bile stained, contained mostly mucous substances . He visited the local doctor for these complaints and took medications but his symptoms did not subside. He gave no history of hematemesis and melaena , difficulty in breathing, fever, cough,

9. History of presenting illness (contd.) hemoptysis, chest pain, bone pain, jaundice, or any contact with TB patients. His bowel and bladder habits are normal. He is normotensive and nondiabetic. With the above complaints he was admitted in this hospital for better management. He also complained of weight loss and anorexia.

10. History of past illness The patient g a ve no significant history of any past medical or surgical illness. Drug history The patient did not take any drug regularly

11. History of allergy The patient gave no history of allergy to any known food or drugs. History of immunization Patient is immunized, as per EPI schedule . Personal history He is a smoker, taking approx. 5-10 sticks/day for the last 20 years. He is non-alcoholic.

12. Family history His family consists of his wife, a son and a daughter. None of his family members and relatives is suffering from such type of illness. Socioeconomic history He comes from a low income background. He lives in a tinshed house. He drinks clean water and uses sanitary latrine. He takes average Bangladeshi meals everyday.

13. Cooperation: Cooperative Appearance: Anxious Body-build: Below average (BMI=16.07) Decubitus: On choice Nutrition: Average Intelligence: Normal General Examination

14. Anemia: Mildly anemic Jaundice: Absent Cyanosis: Absent Clubbing: Absent Koilonychia : Absent Leuconychia : Absent General Examination (contd.)

15. Edema : Absent Dehydration : Absent Pigmentation: Absent Hair distribution: Normal Deformities: Absent Lymph nodes: No palpable accessible lymph nodes General Examination (contd.)

16. General Examination (contd.) Thyroid gland: Not enlarged Neck veins: Not engorged Pulse: 80beats/min Blood pressure: 120/70 mmHg Temperature: 100 o F Respiratory rate: 16 breaths/min

17. Systemic Examination Lips, gum, oral cavity and vestibule appear normal. Abdomen: Inspection: Shape of abdomen: Mildly distended.

18. Systemic Examination (contd.) Flanks: F ull Umbilicus: Centrally placed, not everted, vertically slit Skin condition: Normal Hair distribution: Normal Visible peristalsis: Present

19. Systemic Examination (contd.) Visible pulsation: Absent Visible engorged veins: Absent Hernial orifices: Intact Palpation: Superficial Temperature: Raised Tenderness: Present on the area overlying

20. Systemic Examination (contd.) the lump on the right iliac fossa Muscle guard: Absent Palpation: Deep There was a lump in the right iliac fossa measuring about 4cm × 6cm, rounded in shape, with an irregular surface, firm in consistency, with an ill-defined margin that

21. Systemic Examination (contd.) did not move with respiration, was not fixed with skin and was slightly mobile. Liver and spleen: Not enlarged Kidneys: Not palpable or ballotable Fluid thrill: Absent

22. Systemic Examination (contd.) Percussion: Percussion note: Tympan it ic all over the abdomen, except dull over the lump Upper border of liver dullness: In the 5 th intercostal space on right midclavicular line Shifting dullness : Absent

23. Systemic Examination (contd.) Auscultation: Bowel sound: Present Vascular bruit: Absent Digital rectal examination: On inspection findings were normal. No skin tag, fissure or fistula was seen. On palpation findings were

24. Systemic Examination (contd.) normal. On withdrawal, the finger was not blood stained. Examination of the genitalia revealed no abnormalities.

25. Systemic Examination (contd.) Cardiovascular system: Apex beat: Left fifth intercostal space in midclavicular line First and second heart sound: audible and normal in character. No added sound or murmur present.

26. Systemic Examination (contd.) Respiratory system: Inspection: Chest movement bilaterally symmetrical. Palpation: Trachea centrally placed. Percussion: Resonant in all zones of both lungs. Auscultation: Breath sound vesicular, no added sound present.

27. Systemic Examination (contd.) Genitourinary system: Urinary bladder: Not palpable. Testes: Present and palpable. Scrotum and penis: Normal

28. Systemic Examination (contd.) Nervous system: Higher psychic function: Oriented. All cranial nerves: Intact. Muscle tone & power: Normal. Sensory examination: Normal. Signs of meningeal irritation: Absent.

29. Systemic Examination (contd.) Musculoskeletal system: NAD Integumentary system: NAD

30. Salient Features Mr. Amenullah Bablu , 35 years old married Muslim housepainter hailing from Amtola , Mirpur admitted into this hospital with the complaints of fever for 5 months, lump in the right lower abdomen for 2 months and abdominal pain for the same duration. He was reasonably well 5 months back. Then he

31. Salient Features (contd.) developed a fever, which was low grade, intermittent, rising at evenings, associated with night sweats, not associated with chills and rigors, relieved by antipyretics, and was not recorded. He also noticed a lump, 2 months back, in the right side of his lower abdomen which was initially small but gradually

32. Salient Features (contd.) increasing in size. He also complained of pain in the abdomen for the same duration, which was diffuse, of moderate to severe intensity, cramping in nature, intermittent, and was not associated with any radiation or shifting. The pain was associated with vomiting, which was not projectile, not bile stained, contained

33. Salient Features (contd.) mostly mucous substances. He visited the local doctor for these complaints and took medications but his symptoms did not subside. He also complained of weight loss and anorexia. He gave no history of hematemesis and melaena , difficulty in breathing, fever, cough,

34. Salient Features (contd.) hemoptysis, chest pain, bone pain, jaundice, or any contact with TB patients. His bowel and bladder habits are normal. He is normotensive and nondiabetic. With the above complaints he was admitted in this hospital for better management. On general examination, he was of below

35. Salient Features (contd.) average body build, mildly anemic, non-icteric and his vital parameters were within normal limits. On systemic examination, inspection of the abdomen showed mild distension with visible peristalsis. On palpation, the temperature was raised with presence of a tenderness on the

36. Salient Features (contd.) area overlying the lump in the right iliac fossa. There was a lump in the right iliac fossa measuring about 4cm × 6cm, rounded in shape, with an irregular surface, firm in consistency, with an ill-defined margin that did not move with respiration, was not fixed with skin and was slightly mobile.

37. Salient Features (contd.) Examination of other systems revealed no abnormalities.

38. Provisional Diagnosis?

39. Subacute intestinal obstruction due to intestinal tuberculosis

40. Differential Diagnosis Crohn’s disease Carcinoma Cecum Appendicular lump

41. Investigations for diagnosis CBC with ESR: Hb % - 12.2% ESR - 25mm in 1 st hour WBC – 8200/mm 3 Neutrophil - 69% Lymphocyte - 23% Monocyte - 7%

42. Investigations for diagnosis (contd.) Eosinophil - 1% Basophil - 0% Platelets – 4,63,000/mm 3 Ultrasonogram of Whole Abdomen: Heterogenous mass like area measuring about (7.2x5.2)cm is seen in right iliac fossa region with multiple enlarged lymph nodes largest

43. Investigations for diagnosis (contd.) one is about (1.79x1.91) cm. Impression: 1. GB sludge 2. Mass in right iliac fossa region possibly gut origin with enlarged lymph nodes. Plain X-Ray Abdomen (A/P view) : Distended bowel loops.

44. Investigations for diagnosis (contd.) Colonoscopy: could not be done due to inadequate bowel preparation Contrast CT Scan of Whole Abdomen : Thick wall bowel loops are seen in right iliac fossa region. Proximal bowel loops are mildly dilated.

45. Investigations for diagnosis (contd.) Comment: Suggestive of gut related mass ? ileocaecal TB Advice: FNAC. CEA: 11.30 ng/ml

46. Investigations for diagnosis (contd.) Tuberculin test: (done on 27.06.2016 before admission) Findings: Induration in 14 mm. Comment: Tuberculin test is positive (+ ve )

47. Investigations for diagnosis (contd.) Fine Needle Aspiration Cytology (done on 29.06.2016 before admission) Microscopic Examination: Smears show fair number of degenerated neutrophils, few lymphocytes and occasional histiocytes . Background shows necrotic

48. Investigations for diagnosis (contd.) materials and red blood cells. No granuloma or malignant cell is seen. Dx : Right lumbar swelling (USG guided FNAC): Acute inflammatory lesion

49. Investigations for anaesthetic fitness Random Blood Glucose: 81 mg/dl Serum creatinine: 0.8 mg/dl Serum electrolytes: Na + 146 mEq /L K + 3 . 06 mEq /L Cl - 103 mEq /L Chest X-Ray: Normal findings ECG: Normal findings

50. Management plan Conservative management: Nil per os Nasogastric suction Intravenous fluids Antibiotic Analgesics

51. Management plan (contd.) Catheterisation Blood transfusion Counselling Diagnostic laparotomy: Since symptoms of obstruction did not subside after conservative management, diagnostic laparotomy was done.

52. Date and time: 08 August 2016; 7:10pm Indication: Subacute intestinal obstruction due to i leocecal tuberculosis Anaesthesia : General a naesthesia Operation: Right h emicolectomy Incision: Midline Operation note

53. Procedure: With all aseptic precautions, after proper prepping and draping abdomen was opened through midline incision. After exploration of peritoneal cavity, peritoneal cavity was searched and there was no liver metastasis or peritoneal seedling and no ascites Operation n ote (contd.)

54. was found. Enlarged lymph nodes were found, largest ones of which measured about 3cm. A growth was p resent in the cecum measuring about 7cm by 5cm, which was partially fixed with posterior abdominal wall but was resectable . Right hemicolectomy was done . Operation n ote (contd.)

55. I leum was emptied and ileo-transverese anastomosis was done. After ensuring proper hemostasis and leaving a drain, abdomen was closed in layers. Resected specimen was sent for histopathological examination. Surgeon: Unit 2, Department of Surgery Anaesthetist : Department of Anaesthesia Operation n ote (contd.)

56. Check dressing was done on 3 rd POD. The drainage tube was removed on 8 th POD. Postoperative recovery was otherwise satisfactory, but the patient developed infection at the wound site on 6 th POD. Sutures were Postoperative period

57. removed at the infected site and wound dressing is being performed. Histopathological examination: Mucinous adenocarcinoma grade 3 with lymph node metastasis. Pathological staging ( pTNM ): pT3a pN2 pMx Postoperative period (contd.)

58. Final diagnosis Carcinoma Cecum (Mucinous adenocarcinoma grade 3 with lymph node metastasis. Pathological staging (pTNM): pT3a pN2 pMx)

59. Referral, counselling and followup Patient will be counselled and referred to Oncology department for further assessment and chemotherapy.

60. Thank you