Slides - Pilgrims Hospital
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Transcript Slides - Pilgrims Hospital
RIF pain…an unusual
suspect
HS.
84 year old gentleman
7/52 history of right iliac fossa pain
‘Tightness’ at RIF
Constant
Non radiating
Worse on hip flexion and movement
No fevers/night sweats/rigors
No nausea/vomiting/altered bowel habit
History
Past Medical History
NIDDM
MI – ’98
Right inguinal hernia repair
Vit B12 deficiency
Medications
Metformin
Aspirin
Atorvastatin
Pantoprazole
History
Social History
– Non smoker
– No C2H5OH
Family History
– NIDDM
Systems review
– NAD
Examination
BP 118/66, PR 90, Temp 36.5, Sats 96% on RA
Abdomen soft
Tender at RIF
Guarding on deep palpation at RIF
No distension
Bowel sounds present and normal
DRE- NAD
Investigations
Radiology
Bloods
Hb
WBC
Neut
ESR
CRP
U&E
LFTs
12.7
7.17
4.93
35
6
normal
normal
PFA
– density projected
over Right renal
pelvis (7X5mm),
?renal calculus.
Bowel within normal
limits.
CXR
– NAD
Intra-operative
Laparoscopy
Laparoscopic mobilisation of ceacum
Findings:
– hard appendiceal mass
Converted to laparotomy
Right hemicolectomy
Histology
Diffuse large B cell lymphoma, appendix, germinal
centre type
Margins and lymph nodes free.
Post operative course
Wound infection
Oncology review
CT Thorax, abdomen, pelvis
Discharged on POD 17 with po Antibiotics
Follow up
– 1/12 in our OPD
– 3/12 in oncology OPD
Appendiceal Tumours
Background
Gastrointestinal tract
– is the most frequently involved extranodal site of Non
Hodgkins lymphoma (30-45%).
– 4-20% of all Non Hodgkins lymphoma.
Incidence of primary lymphomas of appendix
– estimated as 0.015% of all gastrointestinal lymphomas.
1% of all appendectomy specimens contain a
neoplasm.
Presentation
Acute appendicitis
Weight loss
Anorexia
Palpable lower quadrant mass
Obstruction/constipation
Nausea/vomiting
Diagnosis- histological
Investigation
History
– similar to appendicitis.
Examination
– tender RIF +/- mass
Bloods
– Normal/Raised inflammatory markers
Radiology (pre op)
– CXR/PFA – perforation/obstruction
– CT ABDOMEN – mass
Histology
Radiology (post op)
– CT TAP - mets
Management
Early detection + high suspicion –
essential.
Surgery
– Appendectomy
– +/- Right hemicolectomy
– +/- lymph node dissection
Types
Divided into 2 major groups
– Carcinoid
occurs at tip of appendix.
– Non-carcinoid
originate at the epithelial lining of appendix.
Produce a thick gelatinous material known as
mucin.
Carcinoid
Most common form (>50% cases)
F>M
Occur in 4th decade of life.
Symptoms
similar to appendicitis.
Carcinoid syndrome – flushing, SOB, diarrhea,
Right sided heart valve disease.
Tx- appendectomy + Right hemicolectomy +
lymph node dissection.
85% 5-year survival rate.
B cell lymphoma
non-Hodgkin's B-cell lymphoma
usually present in second to third
decade of life.
Symptoms
– Like appendicitis
Treatment
– Appendectomy + Right hemicolectomy
Adenocarcinoma
F=M
Occurs 6th decade of life
Rarer but more aggressive type.
Occur in the epithelial lining of the appendix – obstructive symptoms.
Symptoms
– Abdominal pain, constipation, N+V.
Treatment
– Appendectomy + right hemicolectomy.
Prognosis – poorer than carcinoid.
5 yr survival.
– Duke’s A – 94
– Duke’s B – 83%
– Duke’s C – 44%
Pseudomyxoma peritonei
(PMP)
Presence of acellular mucin within abdominal cavity.
Usually has metastased at time of presentation.
Spread
– direct
– rarely through bloodstream or lymphatics.
Sypmtoms
–
–
–
–
Bowel obstruction
Increase in abdominal size
Pelvic discomfort
Ovarian masses
Treatment
– debulking surgery.
Summary
Appendicitis should be the top of your
differential for anyone with RIF pain.
Appendiceal cancer is a rare (and usually an
incidental) finding
Should be suspected in any elderly person
presenting with appendicitis like symptoms
and signs
Histology of ALL patients post
appendectomy should be checked
http://www.ajronline.org/cgi/content/full/178/5/1123 (histology pictures)
http://www.ijpmonline.org/article.asp?issn=03774929;year=2008;volume=51;issue=3;spage=392;epage=394;aulast=Radha
(indian case)
http://www.mdanderson.org/patient-and-cancer-information/cancerinformation/cancer-types/appendix-cancer/index.html
www.medscape.com/viewarticle/431119_3 (normal CT appendix)
http://www.dmvsurgerycenter.com/Portals/0/gensurg.gif (surgery pic)
www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=cmed.section.24834 (info on
adenocarcinoma)
http://www.aboutcancer.com/appendix_cancer.htm
(graph)
http://www.thedoctorsdoctor.com/diseases/
appendix_adenoca.htm - Appendiceal tumors:
retrospective clinicopathologic analysis of appendiceal tumors from
7,970 appendectomies. Connor SJ, Hanna GB, Frizelle FA