case presentation a 47y wm s/ significant pmh presents to ed with a 2 week h/o abdominal pain. pain...
TRANSCRIPT
Case Presentation• A 47y WM s/ significant PMH presents to ED with a 2
week h/o abdominal pain. • Pain is mostly in the LLQ, radiates across the abdomen,
and has progressively worsened since onset. • Patient reports pain is worse with standing and with po
intake, denies any alleviating factors. • Associated sx include nausea, vomiting, decreased po
intake, and no BM in 2 weeks. Prior to this time he had normal formed BM daily.
• He has tried po and pr stimulation of BM s/ results. Prior to the onset of sx he denies BRBPR, melena, constipation, or bowel disease.
• PE: Abdomen distended, TTP throughout, > in LLQ. Guarding s/ significant rebound. Slightly decreased BS.
• WBC 21 w left shift
Left lateral decubitus and upright projections of the abdomen show mildly distended bowel loops.
Case Presentation
CT abd/pelvis c/ contrast shows perforated sigmoid diverticulitis c/ free intraabdominal air.
Case Presentation
• Assessment: Likely diverticular disease of the sigmoid colon with micorperforation.
• Recommendation: X-lap and likely Hartmann's procedure
• Intraoperative Findings: Significantly inflamed and edematous sigmoid colon with a perforation noted on the left mid sigmoid.
• Postoperative Dx: Diverticulitis with perforation of the sigmoid colon
Case Presentation
The Anatomical Basis of Diverticulosis
Introduction
Diverticulum – a sac-like protrusion from a tubular or saccular organ
Diverticulosis – presence of diverticula
Diverticulitis – inflammation of diverticula
Diverticular disease – term encompassing both diverticulosis and diverticulitis
Introduction
Epidemiology Common, up to 65% by age 85 95% in sigmoid colon
Risk factors Age, dietary fiber intake, gender, physical
activity, obesity
“Pseudodiverticula” Mucosa and submucosa herniate through
muscle layer, covered only by serosa
Right colic (hepatic) flexure
Left colic (splenic) flexure
Transverse colon
Ascending colon
Descending colon
Sigmoid colon
Rectum
Cecum
Appendix
Anal canal
Anatomy of the Colon
Illustration by Donna Myers © 2007
Anatomy of the Colon
Anatomy of the Colon
Meyers, MA. 2005.
Anatomy of the Colon
Anatomy of the Colon
Anatomic Basis of Disease
Vasa recta
Laplace
Segmentation
Anatomic Basis of DiseaseVasa Recta
a) normal
b) protrusion marking development of a diverticulum
c) transmural extension
www.accesssurgery.com “Current Surgical Diagnosis and Treatment”
Anatomic Basis of DiseaseVasa Recta
Anatomic Basis of DiseaseVasa Recta
Four distinct sites of formation: each side of the mesenteric taenia mesenteric border of the two antimesenteric
taeniae
Anatomic Basis of DiseaseVasa Recta
Anatomic Basis of DiseaseLaw of Laplace
P=kT/R : pressure P is proportional to wall tension T, and inversely proportional to bowel radius R
Anatomic Basis of DiseaseSegmentation
Smooth muscle contraction separates colon into functionally distinct compartments
Summary
Common disease that can lead to life threatening complications
Pathophysiology directly related to anatomy: colonic structure, pressure and motility
Eat your fiber!
References
Heise CP. 2008. Epidemiology and pathogenesis of diverticular disease. J Gastrointest Surg. Aug;12(8):1309-11. Epub 2008 Feb 16.
Kassahun WT, Fangmann J, Harms J, Bartels M, Hauss J. 2007. Complicated small-bowel diverticulosis: a case report and review of the literature. World J Gastroenterol. Apr 21;13(15):2240-2.
Meyers, MA. 2005. Dynamic Radiology of the Abdomen: Normal and Pathologic Anatomy. “The Colon: Normal and Pathologic Anatomy.” New York: Springer.
Parra-Blanco A. 2006. Colonic diverticular disease: pathophysiology and clinical picture. Digestion. 73 Suppl 1:47-57. Epub 2006 Feb 8.
Petruzziello L, Iacopini F, Bulajic M, Shah S, Costamagna G. 2006. Review article: uncomplicated diverticular disease of the colon. Aliment Pharmacol Ther. May 15;23(10):1379-91.
Sheth AA, Longo W, Floch MH. 2008. Diverticular disease and diverticulitis. Am J Gastroenterol. Jun;103(6):1550-6. Epub 2008 May 13.
Woods K, Williams E, Melvin W, Sharp K. 2008. Acquired jejunoileal diverticulosis and its complications: a review of the literature. Am Surg. Sep;74(9):849-54.
Young-Fadok, T., and Pemberton, J.H. Clinical manifestations and diagnosis of colonic diverticular disease. UpToDate 2003.