This document discusses three cases of acute abdominal conditions seen by a surgical gastroenterologist.
Case 1 involves a 55-year-old male with left lower quadrant pain and fever diagnosed with diverticulitis based on CT findings. The patient underwent left hemicolectomy with sigmoid resection and diverting loop ileostomy.
Case 2 describes a 53-year-old male with abdominal pain found to have an acute SMA thrombosis on CT angiography. The patient was treated conservatively with heparin and antibiotics.
Case 3 involves a 65-year-old cirrhotic male with SMV thrombosis found on CECT. The patient deteriorated clinically despite conservative management and required small bowel resection during
2. Case 1
• 55 year old male
• No Medical co morbidities
• Pain in left iliac fossa since 6 days
• Fever since 5 days
• Chronic constipation since more than 2 yr
• O/E:
– Tachycardia (96/min)
– Other parameters Normal
– P/A: Moderately distended abdomen, severe tenderness
in LIF
3. • USG Abdomen:
– Grade 1 fatty liver
– Gall stones
– Focal edematous thickening of mesentery in LIF with
edematous adjacent descending colon and ileal loop
– R/O: Diverticular ds/Non specific inflammation
• TC: 18 200 Rest normal
• What next?
4. Diverticular disease consists of:
o Diverticulosis: the presence of diverticula within the
colon
o Diverticulitis: inflammation of a diverticulum
o Diverticular bleeding
Types of diverticular disease:
• Simple (75%), with no complications
• Complicated (25%), with abscesses, fistula,
obstruction, peritonitis, and sepsis
5. Choice of
investigation
• CT scan
• Dye study
• Colonoscopy
• X-ray Abdomen
(sensitivity69-98%,specificity75-100%)
(sensitivity62-94% falsenegative2-15%)
(C/I in acute setting)
6. Differential diagnosis:
o Carcinoma of the bowel
o Pyelonephritis
o Inflammatory bowel disease
o Appendicitis
o Ischemic colitis
o Irritable bowel syndrome
o Pelvic inflammatory disease
10. • CT scan IV and Rectal contrast
– Thickened left colon with mesenteric fat stranding
– Large collection retrocolic and mesocolon
– Mild free fluid intraperitoneum
– Small bowel loop adhered in left iliac region with wall
thickening
– leak of contrast in abscess cavity
– No e/o fistulous connection
• Further plan of action…..
11. • Options
– Conserve and antibiotics
– CT/USG guided pigtail
– Laparoscopy and Lavage
– Emmergency exploration
12. Indications for elective surgery
• Two or more episodes of diverticulitis severe
enough to cause hospitalization
• Any episode of diverticulitis associated with
contrast leakage, obstructive symptoms, or an
inability to differentiate between diverticulitis and
cancer
13. Exploration: findings
• Pyoperitoneum appx 50 cc
• Sigmoid and descending up to splenic flexure was
involved
• Terminal ileum densely adhered with sigmoid
• Pus cavity left to sigmoid appx 300 cc
• Multiple sigmoid perforated diverticulitis (pus)
• Inflamed terminal ileum without any fistulous
connection
14. Surgical modality?
• Hartmann procedure (Left colectomy with end
stoma)
• Resection, proximal bowel wash, colorectal
anastomosis with diverting ileostomy
• Resection, bowel was through appendix, colorectal
anastomosis, with ileostomy
• Primary resection and colorectal anastomosis
• With cholecystectomy?
15. In this patient
• Resection (Left extended Hemicolectomy with
sigmoid)
• Proximal colon wash with saline
• Colorectal anastomsis
• Diverting loop ileostomy
• Expected post op events and management?
16. Primary resection
• Associated with a shorter hospital stay
• Associated with reduced morbidity than
with colostomy alone and drainage
• Associated with a lower mortality than with
colostomy alone versus resection (26% vs.
7%)
• Associated with a survival advantage
Rodkey GV, Welch CE. Changing patterns in the surgical treatment of diverticular disease. Ann Surg
1984;200:466–78 (PMID: 6333217).
Aguste L, Barrero E, Wise L. Surgical management of perforated colonic diverticulitis. Arch Surg
1985;120:450–2 (PMID: 3985790).
Finlay IG, Carter DC. A comparison of emergency resection and staged management in perforated
diverticular disease. Dis Colon Rectum 1987;30:929–33 (PMID: 3691263).
Nagorney DM, Adson MA, Pemberton JH. Sigmoid diverticulitis with perforation and generalized
peritonitis. Dis Colon Rectum 1985;28:71–5.
Krukowski ZH, Matheson NA. Emergency surgery for diverticular disease complicated by generalized
and faecal peritonitis: a review. Br J Surg 1984;71:921–7 (PMID: 6388723).
17. Annals of Surgery; Volume 256, Number 5, November 2012
Conclusion
• Primary outcome did not differ
• Strong evidence favoring PA with protective ileostomy
over HP in the treatment of acute left-sided colonic
perforation with generalized peritonitis
• The benefits directly relate to the stoma reversal
operation, which is more likely to occur and safer in PA
• Further investigations are required to identify a group of
patients, which may potentially not require a diverting
ileostomy
18. Case 2
• 53 year old male
• No IHD/DM/HT…
• Acute onset abdominal pain
• Distension
• No fever
• Vitals-stable
• Abdomen-severe tenderness, distended
19. • What are the differentials?
• When to suspect mesenteric ischaemia?
• Blood investigations to support?
20. • Hb-7.8
• TC-10,800
• S.creat-1.3
• ABG-Acidosis
• Lactate(ABG)-3 (Increased)
• USG: asymmetric bowel wall thickening, minimal
free fluid
• What is next step??
31. • Findings of CT Scan?
• Interpretation?
• Helpful in deciding line of management?
• Acute SMA thrombus at origin
• Thickened proximal bowel loops
• No obvious gangrene
50. • Alarming signs/findings on follow up imaging?
• What are the instructions to radiologist while
prescribing the first and repeat scans-
Oral/IV/triphasic/negetive contrast….?
• Blood investigations- interpretation-
ABG/Lactate/TC as marker of gangrene?
51. In this patient
• Condition- improving
• Diet started
• Oral – Clopidogril/Aspirin and Warfarin
52. • Would you encourage oral diet as soon as possible
or keep NBM
• Medical management of arterial thrombosis and
etiological work up in this pt.
• Role of diagnostic Lap in AMI when in dilemma
53. After Discarge
• On follow up (3 months)
• Post prandial pain after 2 hrs of meals
• Black colored stool
• Mild distension
• Occ. vomiting
54. • What do you suspect and further investigation?
• Admit?
• Investigation?
• Imaging?
55. Blood Investigation
• CBC – Normal
• INR – 3.2 (On warfarin)
• RFT – Normal
• LFT – Normal
• Is it due to anticoagulants or ischaemia?
58. Case 3
• 65 year old male
• CLD/DM/HT
• H/o variceal banding – 2 times
• Severe pain in abdomen & distension
• USG- Normal
• X-ray abdomen - Normal
• TC- Normal
• Platelets- 70,000
• Liver/renal function- preserved
• CHILD POUGH Type A
59. CECT
• SMV thrombosis
• PV – Normal
• Thickened bowel wall without any obvious s/o
gangrene
• Cirrhotic liver
• What else you would like to know?
62. • After 12 hrs of admission
– Tachycardia
– Hypotension- ionotrpes started
– Low UO
– ABG – acidosis
• Next action? – Repeat imaging/surgery
63. On exploration
• Gangrene involving distal jejunum and proximal
ileum appx 25-30 cm
• Resection done
• Selection?
– Primary anastomosis
– Stoma
64. In this patient
• Anastomosis without stoma done
• Post op heparin continued
65. • How you will monitor this pt?
• Any other etiological work up?
• Special consideration and precautions in the setting
of CLD?
• Would you like to repeat imaging or second look
exploration or wait? – role and any evidence to
support you decision.