Vic Showalter MS4 December 2018
Edited by John Lilly, MD
30 y/o Female
RLQ abdominal pain
Duration: 1 day
Denies: nausea, vomiting, fevers,
change in stool
No PMH or FH
Vitals: Mild Tachycardia
Physical Exam
Non toxic appearing
RLQ tenderness
No rebound tenderness
Labs Ordered: CBC, BMP, UA, UPT
WBC: 11.8
Appendicitis Gastritis Intussusception Ovarian torsion Diverticulitis Renal stone Constipation
Computerized Tomography
• Single Node• Fat stranding • Possible bowel
wall thickening
Normal structures:Cecum CSmall bowel SBCommon Iliac artery IAPsoas muscle PM
IA
C
SB
PM
• Inferior to previous section
• Visualize cecum• Visualize normal
appendix• No signs of
inflammation Normal structures:Sacrum SExternal and Internal Iliac Arteries EIA IIA S
IIAEIA
• Single node inflammation 9mm diameter with adjacent fat stranding
• Non affected appendix
• No ovarian pathology
Normal structures:Appendix ApOvaries/adnexa OA
Ap
OAOA
One Dx!Mesenteric Adenitis
Pain Control Hydration One dose abx (concerns for appendicitis) Surgery consulted Scheduled for exploratory laparoscopy Laparoscopy yet to be performed
Clinical Symptoms
Children, adolescents, young adults
Uncommon over age of 20
+/- Fever
+/- Nausea and vomiting
Changes in stool consistency
RLQ pain (epigastric)
Rebound tenderness (present in ¼
of patients)
Labs
CBC - elevated white count
CRP - elevated
Work up other possible pathologies first
Diagnosis of exclusion
Helbling et al. Biomedical Research International. 2017
2 Types Primary (no identifiable
underlying cause)
Secondary ▪ Systemic Inflammatory Diseases
(i.e. Lupus)
▪ Malignancy
▪ HIV
▪ Tuberculosis
▪ Infectious (zoonotic: Yersinia enterocolitica)
▪ Gastritis
Pathophysiology Inflammation of mesenteric
lymph nodes Not well understood
Management Primary
▪ Hydration ▪ Pain medication ▪ Self limiting
▪ 2-3 weeks normal duration▪ 10 weeks maximum
Secondary: address underlying etiology
Helbling et al. Biomedical Research International. 2017
Imaging recommended
US best modality
Multiple definitions
▪ 3 lymph nodes > 5mm at short axis
▪ 1 lymph node > 8mm at short axis
▪ Bowel wall thickening
Same definition for CT
▪ Fat stranding
Few adult studies mention CT
Majority of studies pediatric based
Sanchez et al. J Ultrasound Med. 2016
Sanchez et al. J Ultrasound Med. 2016
Macari et al. American J Roentegenology. 2002
Poorly studied imaging efficacy for this disease process No tested sensitivities or specificities for mesenteric adenitis Appendicitis
Sensitivity: 98%
Specificity: 92%
Visualization rates 22-98% Intussusception
Sensitivity: ~ 97.9%
Specificity: ~ 97.8% Mittal et al. Acad Emerg Med. 2013Garcia Pena et al. JAMA. 1999Carroll et al. Acad Radiol. 2017
Radiation Exposure
~3 mSv for CT
No exposure for US
Cost
Abdominal CT w/ contrast: ~ $512 - $5055
Abdominal US: $436 - $1404
Shrimpton et al. Br J Radiol. 2006
1. Acsearch.acr.org. (2018). Appropriateness Criteria. [online] Available at: https://acsearch.acr.org/list [Accessed Dec 7th 2018]2. Helbling R, Conficconi E, Wyttenbach M, Benetti C, Simonetti G, Bianchetti M, Hamitaga F, Lava S, Fossali E, Milani G. Acute
Nonspecific Mesenteric Lyphadneitis More Than “No Need For Surgery. BioMed Research International. 2017 Article IS 9784565
3. Sanchez T, Corwin M, Davoodian A, Stiein-Wexler R. Sonography of Abdominal Pain in Children: Appendicitis and Its Common Mimics. J Ultrasound Med. 2016; 35:627-635
4. Benetti C, Conficconi E, Hamitaga F, Wyttenbach M, Lava S, Milani G, Bbianchetti M, Simonetti G, Helbling R. Course of acute nonspecific mesenteric lymphadenitis: single center experience. Eur J Pediatr. (2018) 177:243-246
5. Neuman, Mark. Causes of Acute abdominal pain in children and adolescents. UptoDate. https://www-uptodate-com.libproxy.lib.unc.edu/contents/causes-of-acute-abdominal-pain-in-children-and-adolescents?search=mesenteric%20lymphadenitis§ionRank=1&usage_type=default&anchor=H23&source=machineLearning&selectedTitle=1~25&display_rank=1#H23 [Accessed Dec 6th 2018]
6. Mittal MK, Dayan PS, Macias CG, et al. Performance of ultrasound in the diagnosis of appendicitis in children in a multicenter cohort. Acad Emerg Med 2013; 20:697
7. Garcia Peña BM, Mandl KD, Kraus SJ, et al. Ultrasonography and limited computed tomography in the diagnosis and management of appendicitis in children. JAMA 1999; 282:1041.
8. Carroll AG, Kavanagh RG, Ni Leidhin C, Cullinan NM, Lavelle LP, Malone DE. Comparative Effectiveness of Imaging Modalities for Diagnosis and Treatment of Intussusception: A Critically Appraised Topic. Acad Radiol. 2017, May; 24 (5):521-529
9. Hryhorczuk AL, Strouse PJ. Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception. Pediatr Radiol 2009; 39:1075.
10. Shrimpton, PC, Hillier, MC, Lewis, MA, Dunn, M. National survey of doses from CT in the UK: 2003. Br J Radiol 2006; 79:968.11. “Find Your Fair Price.” Healthcare Bluebook, CAREOperative,
www.healthcarebluebook.com/page_SearchResults.aspx?CatID=42.