case presentation a 47y wm s/ significant pmh presents to ed with a 2 week h/o abdominal pain. pain...
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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
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Left lateral decubitus and upright projections of the abdomen show mildly distended bowel loops.
Case Presentation
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CT abd/pelvis c/ contrast shows perforated sigmoid diverticulitis c/ free intraabdominal air.
Case Presentation
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• 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
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The Anatomical Basis of Diverticulosis
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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
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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
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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
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Illustration by Donna Myers © 2007
Anatomy of the Colon
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Anatomy of the Colon
Meyers, MA. 2005.
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Anatomy of the Colon
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Anatomy of the Colon
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Anatomic Basis of Disease
Vasa recta
Laplace
Segmentation
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Anatomic Basis of DiseaseVasa Recta
a) normal
b) protrusion marking development of a diverticulum
c) transmural extension
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www.accesssurgery.com “Current Surgical Diagnosis and Treatment”
Anatomic Basis of DiseaseVasa Recta
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Anatomic Basis of DiseaseVasa Recta
Four distinct sites of formation: each side of the mesenteric taenia mesenteric border of the two antimesenteric
taeniae
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Anatomic Basis of DiseaseVasa Recta
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Anatomic Basis of DiseaseLaw of Laplace
P=kT/R : pressure P is proportional to wall tension T, and inversely proportional to bowel radius R
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Anatomic Basis of DiseaseSegmentation
Smooth muscle contraction separates colon into functionally distinct compartments
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Summary
Common disease that can lead to life threatening complications
Pathophysiology directly related to anatomy: colonic structure, pressure and motility
Eat your fiber!
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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.