Presentation on theme: "Drexel University College of Medicine"— Presentation transcript:
1Drexel University College of Medicine Abdominal PainBarry D. Mann, M.D.Professor of SurgeryDrexel University College of MedicinePhilip Wolfson, M.D.
2Mrs. JonesYour patient in the ER is a 62 year-old female with a three day history of LLQ abdominal pain, constipation and fever.
3HistoryWhat other points of the history do you want to know?
4History, Mrs. Jones Characterization of symptoms Temporal sequence Consider the FollowingCharacterization of symptomsTemporal sequenceAlleviating / Exacerbating factors:Pertinent PMH, ROS, MEDS.Associated signs andsymptomsRelevant family hx.
5History, Mrs. JonesAssociated sign/symptoms nausea x 2 days, no vomiting, tendency toward constipation over the years, no blood in stoolsPMHDiabetes MellitusCholecystectomy 15 years agoCharacterization of pain: initially crampy, now steady, increasingly severe in left lower quadrantTemporal sequence: has become more pronounced in last 24 hrsAlleviating / Exacerbating factors: worse with movement and eating, partly alleviated by lying still and drawing legs upwardPMHxDiabetes Mellitutus Cholecystectomy 15 yrs ago
7Physical Examination Mrs. Jones Vital Signs: T= P= R= 22 BP= 126/80General : Well nourished, slightly obese, in moderate distressAbdomen :Inspection – mild distention, symmetric, shallow breathingAuscultation – bowel sounds present but diminishedPercussion – tympanitic; elicits tenderness in LLQPalpation - generally soft, but + LLQ tenderness, guarding and rebound directly and referredRectal: Guaiac neg. scant stool, no mass or tendernessPelvic: no discharge, no-cervical motion tenderness, uterus non-tender, no adnexal masses but tender to palpation on LLQ bimanualRemaining exam non-contributory
13Lab Results, Mrs. JonesThe leukocytosis is consistent with a bacterial infection. The serum electrolytes are normal but the BUN is elevated, suggesting isotonic dehydration. The LFT’s, amylase and lipase are fairly normal indicating that this patient probably does not have significant hepatic or pancreatic disease. The urine is not completely clear, which may be typical of an uncatheterized specimen in the elderly or reflect inflammation contiguous to the urinary tract.
24What next?CT Scan – Acute diverticulitis is the leading diagnosis, and a CT scan is indicated to confirm it and assess its severity (whether there is an abscess, extraluminal air, or extravasated contrast medium).A barium enema and lower endoscopy are contraindicated in acute diverticulitis because they may rupture a sealed area and cause free perforation.
29CT findings in complicated Diverticulitis May see free air or free fluidMay see a localized abscessMay see perforation into adjacent viscera such as bladder, vaginaMay see a phlegmon or abscess involving the abdominal wall or retroperitoneum
31CT ScanCT Scan shows diverticular abscess. No free air, no free fluidWhat next?
32ManagementPercutaneous drainage under ultrasonic or CT guidance is indicated due to the presence of an abscess
33Management What should be done next? Following the drainage of purulent material the patient’s condition improves markedly over the next several days.What should be done next?
34ManagementFollowing clearing of the acute infection, the patient should be scheduled for semi-elective surgery, with resection of the sigmoid colon and a primary anastomosis.
35DiscussionDiverticular disease has become extremely common in middle aged and elderly individuals in industrialized areas where there is a low dietary intake of fiber. Increased pressure in the colon leads to herniations of the mucosa through sites of least resistance, such as where nutrient vessels enter the colonic wall between the teniae. These resulting “false” (because they do not contain all the layers of the bowel wall) diverticula are most common in the left, and especially the sigmoid colon, where the intraluminal pressure is highest.Acute inflammation, or diverticulitis, is a common complication of diverticular disease. The inflamed diverticulum may then perforate, which can either be contained or cause free peritonitis. Symptoms of diverticulitis are typically left lower quadrant pain, fever, and chills. Patients often have a history of chronic constipation. Findings include diminished or absent bowel sounds due to the resulting paralytic ileus, left lower quadrant tenderness, and variable signs of peritonitis, including guarding and rebound. If there is a localized abscess, a mass may be palpable.
36DiscussionA CT scan is most useful to confirm the diagnosis of diverticulitis and determine the extent of the disease, which will affect treatment. Most cases of uncomplicated inflammation will respond to intravenous antibiotics, which should be active against anaerobes and gram negative aerobes. The presence of an abscess, as in the current patient, mandates percutaneous drainage; once the infection is controlled, resection of the involved segment of colon should be performed. If there is free perforation with peritonitis, emergency laparotomy is warranted with resection of the affected segment of intestine; a temporary colostomy is necessary in the presence of a purulent infection due to the high incidence of anastomotic breakdown under these conditions.In the case of uncomplicated diverticulitis that responds to antibiotics, elective surgical resection is usually recommended after the second attack requiring hospitalization.