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about thicken bowel wall on CT

Discussion in 'Surgery and Surgical Subspecialties' started by wawa, Jan 5, 2009.

  1. wawa

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    can please give me some comments on one of my exam questions..

    - 40 years old woman with history of DM, presented with 2 days history of left lower quadrant abdominal pain and fever. CT scan showed thicken bowel wall over sigmoid colon.

    it asked for the diagnosis and initial treatment, followed up further investigations.

    i am totally confused in this question. it wanted me to give a very specific answer

    thank you so much!!!:love:
     
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  3. Winged Scapula

    Winged Scapula Cougariffic!
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    It seems to be a fairly detailed question for a pre-med student which leads me to suspect that this is a request for medical advice.

    Thus, I am not sure what you are confused about. It is asking:

    What is the differential diagnosis for left lower quadrant abdominal pain?
    Which one of those would show a thickened sigmoid colon on CT scan?
    What is the treatment for this common ailment?
    How would you follow the patient after treatment?
     
  4. beaverfetus

    beaverfetus poo-tee-weet?
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    hmm, my parsimonious interpretation is that he inappropriately listed as pre-med instead of medical student, a distinction which might be confusing to a foreign medical student
     
  5. Dimoak

    Dimoak Member
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    Is this your interpretation of the CT, or was this all of the information provided in the question? You'd probably need a CBC and maybe an US for a somewhat feasible ddx.
     
  6. Winged Scapula

    Winged Scapula Cougariffic!
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    You may be correct. If so, please accept my apologies for being suspicious that a new poster would make this their first foray into our forum.

    Really?

    I (and I'm sure most of the residents and final year medical students here) could tell you what the diagnosis was without the CT scan (based on the reported symptoms) and we would be right the vast majority of time.

    The CBC might be useful for confirmation of an infectious process but I'm not sure how the US adds anything to what is presumably a fairly clear cut diagnosis with concordant CT, H&P findings. In a young female, there is not a lot down in the left lower quadrant which produces this disease pattern - fever, pain, thickened sigmoid colon.

    What is your DDx?
     
  7. Dimoak

    Dimoak Member
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    The point I was trying to make was that there should be a CBC and possibly US done prior to ever zapping a pt who c/o LLQ. The vast majority of the time, CT would correctly dx diverticulitis, but if you miss a neoplasm, and don't document enough valid etiology for your initial suspicion of divert, it may be hard to defend later on.
     
  8. SLUser11

    SLUser11 CRS
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    I understand your point with the CBC, which would come before the CT, but I'm lost on the utility of ultrasound in this situation. Are we talking about an abdominal ultrasound?

    As far as missing a neoplasm, that can happen regardless of what you do, which is why these patients get colonoscopies after they've recovered from their diverticulitis.

    While technically you don't even need a CT to diagnose and treat diverticulitis, I personally will get it on nearly everybody, especially with the changing definition of "Complicated diverticulitis" and changing indications for sigmoidectomy.
     
  9. maxheadroom

    maxheadroom Rhinestone Cowboy
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    Maybe three years of plastic surgery training have dulled my general surgery knowledge, but I can't think of any reason to get an U/S of something like this. I suppose it might be reasonable if you thought there was a gynecologic problem and didn't already have the CT.
     
  10. Winged Scapula

    Winged Scapula Cougariffic!
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    1. We all know that in most cases the patient will have been CT scanned before you are even called to see him/her in the ED.

    2. We understand the point of the CBC; it should be done although your comment said it was "probably needed to make a feasible diagnosis". I don't seen how the CBC really helps much except as confirmation that there's an inflammatory/infectious process going on.

    3. As others have said, I'm not sure about the utility of the abdominal US. How does it help in your differential if you are suspecting a neoplasm? I get its utility in a female with right lower quadrant pain, but left? As noted above, these patients will get scoped anyway, so I fail to see how a US helps "defend" your practice. It just seems so low yield and a waste of time since you will almost always be getting a CT anyway.

    I'm not trying to be dense, I really don't follow your reasoning.
     
  11. Dimoak

    Dimoak Member
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    That's true, but there are also many old school ED docs who still feel diverticulitis is a physical diagnosis, and may say "40yo F c/o fever, LLQ pain x 2 days, Hx of DM, US r/o gyn pathology, elev WBC, diverticulitis?". Chances are, the pt would get zapped before leaving the facility anyway, but I was formulating my response to the OP based on the information presented in the exam question (a CBC + H&P and US r/o of gyn culprits could probably call diverticulitis [40 is still a child bearing age] before zapping would confirm it via sigmoid thickening).
    I was approaching the question as academic and not necessarily clinical. If all the information I had was LLQ pain, fever, and thickening at sigmoid (seemed like a bit of an incomplete read (distention?, perfusion?), which is why I asked if this was the impression the OP got from the study, or whether that was simply all of the information presented in the question)., the Hx of DM could even have been put there to suggest ischemic event (perhaps of the small intestine, not volvulus). WBC elevation would likely mean diverticulitis, but if accompanied by acidosis, this can rule in ischemia. If all we know is thickening at sigmoid without any other impressions (both from imaging studies and physical workup). Yes, in the usual clinical setting, small bowel ischemia rarely masquerades as diverticulitis, but maybe the question wanted us to consider that given that DM was mentioned. I know I'm just reaching at things at this point.
    I should've specified that I meant eUS for neoplasm as a further investigation. But I'm not aware of any ways to rule out neoplasm without getting in there, which is counter-indicated during inflammation. I was mostly trying to answer the OP's question, but I got off-track in overanalyzing the question and am sorry about the confusion. :)
     
  12. wawa

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    thank you so much!!
    maybe i better post a full version of the question, but still no much added information

    40year old with 90kg weight and with IDDM was admitted through the casualty department due to LLQ pain and fever for 2 days. PE showed tenderness at Left illac fossa. CT scan showed thickened bowel wall over the sigmoid colon.
    (a) what is the MOST likely diagnosis
    (b) what is the initial treatment of choice?
    (c) if he recovers with you treatment mentioned in (b), what are the options for further investigation?
    (d) after the investigations as mentioned in (c), what is your recommended plan for further management and why?

    so base on the question, i guess the prof who made this question, think the answer is pretty obvious and the CT features should be very typical gwa!?
    i suppose no USG was being done (or at least not mentioned).
     
  13. SLUser11

    SLUser11 CRS
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    That's fine, although it's a slippery slope once you start flexing the brain too much. If you do this in front of a preceptor/resident, you may be opening a can of worms, especially since you're now asking for an ABG to eval for acidosis, and you're introducing a diagnosis (SB ischemia) that's pretty far down the list on the differential. This may open you to new pimp questions that you wouldn't have needed to endure.

    What I've found as I've gotten farther away from the first two years of med school is that standardized tests and preceptors alike are less often looking for zebras. They're instead seeing if you can diagnose and work up common disease in a safe and efficient manner. This is true of the shelf, Step 2, ABSITE, etc. If it looks like a duck, and quacks like a duck, it's not mesenteric ischemia (in this patient).

    Endoscopic Ultrasound? I think once again this "brainstorming" can get you in trouble. Pelvic ultrasound I could get behind a little, but endoscopic ultrasound is a specialized test where the main utility in the above question would be to evaluate the extent of invasion of a previously-established rectal cancer.....

    Excuse me, but we're arguing here, and have no interest in actually answering the OP's questions.......


    Okay, fine. Based on the above scenario:
    A. Acute diverticulitis
    B. IV antibiotics, IV fluids, and bowel rest, although it would be easy to argue that you can feed the patient......
    c. Colonoscopy (or flex sig depending on who you ask) 6 weeks out or so. Other options not really relevant, but I guess include CT colonography, barium enema, watchful waiting......
    d. This is assuming that the patient recovered from "uncomplicated diverticulitis." Previous recommendations for a 40 yo would have been sigmoidectomy, but now they are really changing to watchful waiting, with sigmoidectomy after 2-3 episodes of disease or an episode of complicated disease.
     
  14. Dimoak

    Dimoak Member
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    I agree completely. As WS stated, in the vast majority of clinical cases, you would have done an H&P, would probably have labs and a CT. I was just suggesting that the CBC information (as well as H&P impressions) should be there when you're writing the case up. Certainly in a clinical setting, or during an inservice, it wouldn't make much sense to suggest a 2/1000 atypical SBI presentation when it's vastly more likely that it's diverticulitis. I was also kinda trying to suggest checking for a red herring, but it was inappropriate in this case.
    Once again, no arguments from me here. I was just trying to demonstrate to the OP that labs(CBC, Icon, BMP, UA are a standard of care in LLQ pain, unless I'm mistaken) and PE should be included in the workup. Why would you omit that information if it's likely to be available?
    My logic was pelvic ultrasound to r/o gynecologic ddx, and endoscopic ultrasound as a virtual colonoscopy to r/o neoplasm and perforations, thereby eliminating the need for more CT and a barium enema which could leak through perforations. I understand that the appropriate clinical route would likely be H&P, labs, CT, colonoscopy 5 weeks later (assuming typical noncomplicated case). I'm sorry if I came off as argumentative as that wasn't my intention.
     
    #13 Dimoak, Jan 6, 2009
    Last edited: Jan 6, 2009
  15. Winged Scapula

    Winged Scapula Cougariffic!
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    Good advice...residents learn to never say anymore than they have to. Its good practice for your oral boards when your examiners will let you hang yourself with any sort of rope you provide them.

    I like how I've gone from focusing on the obvious, to looking for zebras to back to looking for the obvious.

    This is surgery not internal medicine where we don't go on academic missions of mental masturbation. Obviously if your DDX is wrong, then other investigations come into play, but I absolutely agree...the OP's professor is likely looking for basic medical knowledge and not some cause WAY down on the list.
     
  16. dynx

    dynx Yankee Imperialist
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    While that may be the case if I'm admitting to someone elses team my strong inclination would be towards:
    PO Cipro/flagyl...D/c home, thank you come again!
     
  17. Winged Scapula

    Winged Scapula Cougariffic!
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    Well, that would depend on the severity of the disease, any associated complications such as an abscess, etc. wouldn't it?

    PO Abx certainly have their place, but not in all cases of acute diverticulitis.
     
  18. SLUser11

    SLUser11 CRS
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    That's fine, as long as you don't do it in a clinical setting in front of people grading you.

    I'm not sure how good endoscopic ultrasound is at your institution, or how widely available it is, but now you've suggested shoving an ultrasound probe up two orifices (V and A, not vagotomy/antrectomy) to save the patient a trip through the scanner. In general, EUS would not be a good test for perforation, or any pathology more than 15-20 cm above the anal verge. Also, a mass and a pericolic abscess can look similar on sono (and CT) in the inflamed pt. As for the barium, that is only appropriate 6 weeks later, otherwise you'd use something less caustic to eval for perforation.

    I guess my point is that you can be docked serious style points for just "throwing things out there" when asked a direct clinical question. If you know something you think the staff doesn't, and start arguing about the benefits of virtual colonoscopy or whatever, you're just going to come off looking arrogant, and once again will be docked points.

    K-I-S-S

    Of course. But, with fever, or any other systemic symptoms, the safe med-student level answer to a standardized question is admission and IV abx.
     
  19. SocialistMD

    SocialistMD Resident Objectivist
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    To echo SLUser's comments, how about a simple colonoscopy instead?
     
  20. Dimoak

    Dimoak Member
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    As I mentioned in a previous post, I am not challenging the widely accepted standard of care for diverticulitis workup, which includes colonoscopy after inflammation has subsided. I was posting from the purely theoretical angle that we had a pt who was a female of childbearing age, c/o LLQ pain and fever, an incomplete Hx, no PE, and nothing else with the exception of thickening sigmoid wall. The points I was trying to make were:

    1.) A good Hx, PE, bloodwork, and in the case of a female, US to rule out gynecologic ddx, you can call diverticulitis without needing a CT.
    2.) Once the inflammation diminished, this person would get a colonoscopy. If you still had reason to suspect neoplasm despite an unremarkable colonoscopy, then next step would be EUS to check under the surface. In an inflamed colon, you're probably not shoving anything in there, but in a non-inflamed colon, lesion type should be differentiable. You wouldn't need to go past 20cm, because neoplasm-related LLQ pain that isn't evident in a colonoscopy would generally be sub-lumen and rectosigmoid.

    I also definitely agree with the mantra "Answer questions in less words than they were asked, and don't answer questions you weren't asked". And I don't deny that this has been little more than mental masturbation. :)
     
  21. Just out of curiosity, what's your background? Where are you in your training (or what field are you in?)? The "Post-Doc" descriptor confuses me.
     
  22. SocialistMD

    SocialistMD Resident Objectivist
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    I never had a reason to suspect neoplasm in the first place.
    So, basically, you are saying you weren't trying to answer the OP's question at all with this answer?
    I guess you tried to explain in your next post that you think fever and LLQ pain is better evaluated with an ultrasound and CBC, but then it gets back (again) to the fact that you weren't trying to help answer the initial questions at all but instead were making a social commentary as to the proper workup for LLQ pain/fever. Would your answer on the exam be a diatribe about how the CT should have never been done, so you were going to ignore it and the diagnosis it gave you and instead order a CBC and an ultrasound rather than just answering how to treat and follow-up a patient with diverticulitis?

    I know I'm being kind of an ass with my reply, but it just seems like you are trying to worm your way out of an odd (albeit I'm sure a very well-intentioned) answer that was questioned by other people on this forum.

    I don't disagree that a pelvic ultrasound is probably a better starting point than a CT for a sexually active woman of reproductive age with LLQ pain and fever if that is all you are told (more for a concern for PID, TOA, ectopic pregnancy than cancer, as most ovarian cancers do not present with fever), but you now have a CT that shows sigmoid inflammation. I doubt an ultrasound-free workup for LLQ pain with fever that had a CT showing inflammation of the sigmoid would be a strong case for a prosecuting attorney's case of a missed diagnosis of ovarian cancer and I'm sure a medical school exam wouldn't try to trip up a student like that, particularly on a surgical rotation (which, based on the fact that the OP decided to post the question in the surgical forum and not the OB/Gyn forum, I assume this was).

    I guess my point is, there are seven replies on this thread (and another four by you trying to justify your statement) based on what you said and how many people didn't see why you would start down that line of thinking. You definitely didn't adhere to the "less is more" philosophy, and if this was truly just mental masturbation, you have more time on your hands than I do, and I'm in lab.
     
  23. Dimoak

    Dimoak Member
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    That's fine, but in a case where all you had was age, gender, LLQ pain, fever, and CT showing sigmoid thickening. Diverticulitis comes to find first, but there isn't enough information to rule out any other ddx.
    The OP's initial question specifically asked for a diagnosis, and I requested additional information because I felt there wasn't enough information provided to answer the question that was asked. The OP later clarified that the question was asking for the most likely diagnosis, and SLUser11 answered it. My responses after my initial post in this thread all addressed questions raised about what I wrote. If I was taking a written exam that asked for a diagnosis and treatment with only the aforementioned exhibits, I would answer that diverticulitis is the likeliest cause of the pt's symptoms and to treat it as such (including colonscopy followup once it's indicated), but more information such as CBC and perhaps ultrasound would be needed to confirm it. If this was a clinical case, I would just do a physical, CBC, probably CT, treat sx, and scope a few weeks down the line.

    I never suspected ovarian cancer specifically, as that wouldn't cause inflammation at the sigmoid unless it's invaded, in which case there would be other etiology in the pt. I was addressing neoplasm that could cause thickening at sigmoid and LLQ pain, which would include sublumenar neoplasm. I threw neoplasm out before colonoscopy was even mentioned, as that's one of the primary reasons a <50yo F would get a colonoscopy as a followup for LLQ pain and colon inflammation.

    I did not word my responses carefully enough in this thread, and don't deny yours (or anyone else's conclusions) based on that. I don't post on forums very often, and when I do, it's often because I feel I may have something to contribute to the discussion. It's obvious that this was not the case, and I'm just irking people on this forum, so I'm going to leave this thread alone. I apologize if my lapse in forum judgment annoyed anyone.
     
  24. SLUser11

    SLUser11 CRS
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    Please don't misinterpret us. You are welcome to post in the surgical forums, and you don't have to be a surgical resident to have an opinion. On the contrary, we thrive off of other opinions, because it gives us a chance to argue, which as you can tell, we love to do.

    Obviously, you are argumentative as well, which makes you fit in quite well. It's just that on this topic, you were wrong. It doesn't mean you need to swear off the Surgical forums altogether. You can, however, learn from this to some degree, as you can see now that the farther you dig yourself into a hole, the harder it is to get out.


    Lets all hug now.

    Anyway, I can't help but mention, due to my nature, that I just can't see EUS being anywhere in your treatment algorithm, especially if its utility is limited to detecting lesions "under the surface" near or below the rectosigmoid junction. It is definitely not the next step if you have a normal colonoscopy.

    Anyway, please don't be scared away. We need some variety here.....
     
    #23 SLUser11, Jan 8, 2009
    Last edited: Jan 8, 2009
  25. JackADeli

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    First, my apologies if my reply is duplication to others. I just read some of what was being posted and thought I might streamline the mental gymnastics. This is mostly for the medical students considering shelf exams, etc...
    For med students:
    gyn, bowel, or any other pathology can give you an elevated WBC. It is quite a non-specific finding.... you can actually get an elevation in WBC from a long night of binge drinking!!!
    (see response towards end re: US or re-specified "eUS")
    The general first step in considering a gyn pathology would likely be a urine or serum bHCG.... not US. In fact, US can and does miss a large amount of gyn path. US for gyn is often a secondary/confirmatory step.
    alot of points in this reply.
    1. from an exam standpoint.... often all you get is the thickening. distention you should get from PE. Often, you don't get much information about perfusion.
    2. Again, WBC elevation is not specific. Thus, I would avoid jumping to the conclusion, "elevation would likely mean diverticulitis".
    3. Ischemia is ALWAYS a consideration in abdominal pain.... you often consider it in clinical context and disregard(or drop lower on DDx considerations) if clinical context is not suggestive. I don't think small bowel ischemia was ever anywhere in my top 20 DDx for LLQ pain... with thickened sigmoid. (note, I say "always", because you try to think of and quickly rule out the most deadly/dire things quickly. which is what I would do with any passing thought of SB ischemia in this scenario.)
    4. WBC elevation and acidosis does NOT "rule in ischemia".
    That thought process will get you failed on written and oral board questions. The one thing the boards always reminds you is that the question is not meant to "trick you". If someone really wanted you to consider SB ischemia with LLQ pain and thickened sigmoid.... then it must be the 10th question in your third room at the oral exam and you have impressed them so much they are throwing everything they can think at you because you are smoking!!!
    Yes, overly so.
    Now to eUS.
    1. you first went on about US to rule out gyn path. see my earlier reply.
    2. eUS would NOT be an ED study.
    3. eUS would not be my choice for ruling out gyn path.
    4. eUS would be a consideration after identification of a tumor/malignancy in a specific setting. (see number 1, 2, & 3)
    5. if you have a patient LLQ pain & thickened sigmoid, I would assess. treatment maybe non-operative or operative. Nonetheless, US would never be used by me in THIS clinical scenario in the acute setting. Once the patient gets past THIS acute setting....
    complete colonoscopy around 6 weeks out from acute setting.
    if neoplastic pathology found at colonoscopy, I would proceed to staging. eUS would be used depending on the findings at colonoscopy... i.e. location/etc...
    I generally agree.... I would further go on and say eUS is not a modality I would use to "detect" a lesion so much as to define its depth/extent after already previously detected.


    thus my penny.
    again, I apologize if this was a duplicate of others.

    J
     
    #24 JackADeli, Jan 11, 2009
    Last edited: Jan 11, 2009
  26. Gastrapathy

    Gastrapathy no longer apathetic
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    Just as an aside, bowel wall thickening absent evidence of surrounding inflammation is an incredibly common CT finding that is usually...NOTHING (peristalsis). These get labeled as colitis/diverticulitis/IBD depending on the distribution all the time.

    The OP's case sounded like the patient might be sick but bowel wall thickening absent other findings can be a total red herring. There should be fat stranding and other signs of pericolonic inflamm.
     
  27. JackADeli

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    agreed. it can be a very non-specific finding or "technique" variation of no significance... in the absence of other evidence.
    agreed, bowel wall thickening as an incidental finding may very well be nothing. However, in the presence of illness, abdominal pain localized to the area in which bowel thickening is seen...should raise concern. As for fat stranding, remember that not all bowel inflamatory pathologies will always give you classic fat stranding on your CT-scan. Much is related to technique and patient body habitus. You need fat to strand...
    I have seen some of the worst appendicitis cases with no significant CT findings or minimal findings. In others, the CT-scan appeared very, very abnormal but the gross view through the midline zipper was very underwhelming.
    CT-scan and other imaging modalities are often a tool and additional data points to help you. They are often non-diagnostic.

    J.
     

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