1. To operate or not to operate?

2. Case presentation GP referral to ED, BIBA.
PC: Collapse and a fall at home.
Had painful right chest wall
She was unable to recall the event,
Had no dizziness, headache, vomiting.

3. PMH : 1. A.Fibrillation
2. Parkinsons
3. Hypertension
4. IHD
5. Hx of hysterectomy
Medications : Warfarin, Dilzem, Bumex
Allergies: Penicillin
Social Hx: lives alone , no home help.

4. O/E GCS 15/15, PEARL BP 147/90, Spo2 95%, HR 77, RR 19, Temp 36 C
Occipital scalp hematoma with sutured laceration.
CVS: irregular heart rate.
Chest: Bilateral air entry with wheezing and
Abdomen : soft, non tender

5. Blood investigations Haemoglobin 12.9 g/dl
White Cell Count x10^9/l
CRP mg/l
INR
U&E (N)
LFT (N)
Troponin I * ng/ml ( <0.035 ) (>0.1 is positive) ( = equivocal)
ECG: nil acute.

6. Plan Admitted under the medical care.
Admission plan: antibiotics, analgesia, hold warfarin, telemetry, combivent, physio, BNP, Troponin

7. 2 days later developed sudden abdominal pain with vomiting.
Vomited 3 times bilious and dark, moving her bowels

8. Surgical consult O/E: BP 95/52, HR 78, Temp 36, SpO2 96%
Distended Abdomen,
Generalised tenderness with
central guarding.

9. Repeat bloods White Cell Count 3.3 x10^9/l CRP 61.6 mg/l
Urea * mmol/l
Creatinine * umol/l
Lactate mmol/l

10. Provisional surgical diagnosis :
Acute abdomen
?? Ischaemic bowel

11. What would you do??

12. Patient & Family
The condition explained and discussed with the patient and family, including the high mortality associated with surgery in her case.
Decision was taken to go ahead and
operate.
However, she was NFR in the event of cardiac arrest.

13. Intra-operative details
Generalized purulent peritonitis
Thickened loop of small bowel (mid ileum) with few diverticula, one with sealed perforation. Scattered diverticula in rest of ileum.
Multiple colon diverticula – with no complication.
Midline incision
Generalized purulent peritonitis
Thickened loop of small bowel ( mid ileum) with few diverticuli, one with sealed perforation. Scattered diverticuli in rest of ileum.
Multiple colon diverticuli – no e/o perforation or inflammation.
No appendix found
Procedure
Thickened loop of small bowel was resected with primary side to side anastomosis done. General peritoneal lavage. Pelvic drain.

14. Procedure
Thickened loop of small bowel was resected with primary side to side anastomosis done.
General peritoneal lavage.
Pelvic drain.

15. Small bowel diverticula

16. Overview
Small bowel diverticula occur most frequently in the duodenum where they are usually asymptomatic.
In one retrospective review of 208 patients, diverticula were located in
duodenum
jejunum or ileum in
all three segments
79 %
(complications rate 13%)
18 %
(complications rate 46 %)
3 %

17. Pathophysiology The cause of this condition is not known.
It is believed to develop as the result of abnormalities in - peristalsis,
- intestinal dyskinesis, and
- high segmental
intraluminal pressures.
The resulting diverticula emerge on the mesenteric border.

18. Classification Intraluminal or extraluminal.
Intraluminal diverticula and Meckel diverticulum are congenital.
Extraluminal diverticula

19. Presentation Usually asymptomatic. Presents with comlications:
- Diverticular pain
- Bleeding
- Diverticulitis
- Intestinal obstruction
- Perforation and localized abscess
- Malabsorption
- Anemia
- Biliary tract disease
- Volvulus - Intestinal obstruction
- Enteroliths - Intestinal obstruction
- Bacterial overgrowth - Flatulence

20. Duodenal diverticula:
These vary from a few millimeters to several centimeters and may be multiple.
Approximately 75% occur within 2 cm of the ampulla of Vater.
It is associated with increased incidence of biliary stones, pancreatitis, and biliary and pancreatic anomalies.
Incidence increases with age.
50% of cases have associated colonic pseudodiverticulosis.

21. Jejunoileal diverticula:
Duodenal and Meckel diverticulum excluded, small bowel diverticula are most common in the proximal jejunum.
They usually are multiple and vary from a few millimeters to 10 cm.
located on the mesenteric border within the leaves of the mesentery.
are frequently associated with small intestine motility disorders,
such as progressive systemic sclerosis, visceral myopathy, and visceral neuropathies.

22. Hemorrhage and pancreaticobiliary disease are the most common complications of duodenal diverticulum,
Diverticulitis and perforation are more common with jejunoileal diverticula.

23. Intraluminal diverticula:
These are congenital diverticula resulting from defective recanalization of duodenal lumen during fetal development.
These structures are believed to start as a fenestrated diaphragm that, over time, transforms into diverticulum as a result of peristalsis.
It occurs singly and has duodenal mucosa on both sides. Intraluminal diverticula are usually located in the second part of the duodenum and can manifest at any age.

24. Risk factors to acquired pseudodiverticula:
Low-fiber diet
High-fat diet
Advancing age
Heredity: No evidence indicates that it is.
Systemic sclerosis
Visceral myopathy
Visceral neuropathy

25. Investigations Lab tests: limited value Radiological. Endoscopy. CT ,
double contrast barium meal and enteroclysis is useful in diagnosis but is contraindicated in acute diverticulitis or perforation.
Double balloon enteroscopy may useful . Capsule endoscopy is excluded in acute diverticulitis, perforation, or small bowel obstruction

26. Managing SB diverticular Disease
Medical /conservative : abdo pain, bloating, malabsoption
Consultation to gastroenterologist/surgeon
Diagnostic and therapeutic endoscopy
Surgical : bleeding, perforation, obstruction, pseudoobstruction, fistula (rare)
Diet

27. References Emedicine.com Uptodate
Butler et al.Journal of Medical Case Reports 2010

28. Thank you..