Drexel University College of Medicine Abdominal Pain Barry D. Mann, M.D. Professor of Surgery Drexel University College of Medicine Philip Wolfson, M.D.

Mrs. Jones Your patient in the ER is a 62 year-old female with a three day history of LLQ abdominal pain, constipation and fever.

History What other points of the history do you want to know?

History, Mrs. Jones Characterization of symptoms Temporal sequence Consider the Following Characterization of symptoms Temporal sequence Alleviating / Exacerbating factors: Pertinent PMH, ROS, MEDS. Associated signs and symptoms Relevant family hx.

History, Mrs. Jones Associated sign/symptoms nausea x 2 days, no vomiting, tendency toward constipation over the years, no blood in stools PMH Diabetes Mellitus Cholecystectomy 15 years ago Characterization of pain: initially crampy, now steady, increasingly severe in left lower quadrant Temporal sequence: has become more pronounced in last 24 hrs Alleviating / Exacerbating factors: worse with movement and eating, partly alleviated by lying still and drawing legs upward PMHx Diabetes Mellitutus Cholecystectomy 15 yrs ago

Physical Examination What would you look for?

Physical Examination Mrs. Jones Vital Signs: T= 101.2 P= 100 R= 22 BP= 126/80 General : Well nourished, slightly obese, in moderate distress Abdomen : Inspection – mild distention, symmetric, shallow breathing Auscultation – bowel sounds present but diminished Percussion – tympanitic; elicits tenderness in LLQ Palpation - generally soft, but + LLQ tenderness, guarding and rebound directly and referred Rectal: Guaiac neg. scant stool, no mass or tenderness Pelvic: no discharge, no-cervical motion tenderness, uterus non-tender, no adnexal masses but tender to palpation on LLQ bimanual Remaining exam non-contributory

What is your Differential Diagnosis?

Laboratory What would you obtain?

Labs ordered, Mrs. Jones CBC Electrolytes LFTs Amylase Lipase PT/PTT Hb Hematocrit WBC Electrolytes LFTs Amylase Lipase PT/PTT Urinalysis

Lab Results, Mrs. Jones CBC Electrolytes 134/101/3.5/23 Hb 12.4 Hematocrit 35.2 WBC 16.4 Electrolytes 134/101/3.5/23 LFTs Bili = 1.1, AST=45, ALT=47, Alk Phos= 104 Amylase 89 (nl=80-100) Lipase 44 (nl=30-90) PT/PTT - pending U/A – 5 RBCs/hpf 15 WBCs/hpf

What do you think of her Labs?

Lab Results, Mrs. Jones The 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.

Interventions at this point?

Interventions at this point? Start IV with Ringers Lactate or similar isotonic crystalloid solution Administer broad spectrum antibiotics

Studies What further studies would you want at this time?

Studies, Mrs. Jones Obstruction Series? Acute Abdominal Series Flat and Upright Abdomen

Studies – obstruction series The Obstruction Series shows that there is some small bowel dilatation consistent with ileus; otherwise a non-specific gas pattern. No free air, no air fluid levels.

What is the Differential Diagnosis at this point?

Differential Diagnosis Diverticulitis Diverticulitis with Abscess Appendicitis Tumor +/- perforation Colonic ischemia / infarction Inflammatory bowel disease UTI

What next?

What next? CT Scan?

What 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.

CT Scan Can you describe the CT findings suggestive of Diverticulitis?

Consider the following Thickened bowel wall Involved segment containing diverticuli (may see contained air/fluid) Fat stranding to suggest local inflammation Localized Peri-colonic fluid or air

Complicated Sigmoid Diverticulitis

CT findings in complicated Diverticulitis May see free air or free fluid May see a localized abscess May see perforation into adjacent viscera such as bladder, vagina May see a phlegmon or abscess involving the abdominal wall or retroperitoneum

CT Mrs. Jones

CT Scan CT Scan shows diverticular abscess. No free air, no free fluid What next?

Management Percutaneous drainage under ultrasonic or CT guidance is indicated due to the presence of an abscess

Management 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?

Management Following clearing of the acute infection, the patient should be scheduled for semi-elective surgery, with resection of the sigmoid colon and a primary anastomosis.

Discussion Diverticular 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.

Discussion A 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.

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