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&sectionRank=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.