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Flashcards in Lower GI - Toronto Notes Deck (80):
1

What are the most common sites for the tumours of the small intestine?

  • Terminal ileum
  • Proximal jejunum

2

Outline the types of polyp disease

  • Adenomas
  • Hamartomas
  • Familial adenomatous polyposis (FAP) 
  • Juvenile polyps 
  • Other
    • leiomyomas
    • lipomas
    • hemangiomas 

3

What are the risk factors for adenocarcinoma? 

  • FAP
  • History of colorectal cancer
  • HNPCC

4

What are the clinical features of an adenocarcinoma? 

  • Early metastasis to lymph nodes
  • 80% metastatic at time of operation
  • Common - abdominal pain - general 

5

What are the clinical features of a carcinoid tumour? 

  • Nausea
  • Vomiting
  • Anaemia
  • GI bleeding
  • Jaundice 
  • Slow growing - usually asymptomatic, incidental finding 
  • Obstruction, bleeding, crampy abdominal pain, intussusception
  • Specifically:
    • hot flashes, hypotension, diarrhea, bronchoconstriction, right heart failure 
    • requires liver involvement  - lesion secretes serotonin, kinins and vasoactive peptides directly to systemic circulation (normally inactivated by liver) 

6

What are the risk factors for small bowel lymphoma? 

  • Crohn's
  • Celiac
  • Autoimmune disease
  • Immunosuppression
  • Radiation therapy
  • Nodular lymphoid hyperplasia 

7

What are the clinical features of a small bowel lymphoma? 

  • Fatigue, weight loss, fever, malabsorption, abdominal pain 
  • Anorexia, vomiting ,constipation and mass
  • Rarely:
    • perforation
    • obstruction 
    • bleeding
    • intussusception

8

What are the risk factors for metastatic disease in the small bowel? 

  • Melanoma
  • Breast cancer
  • Lung cancer
  • Ovarian cancer
  • Colon cancer
  • Cervical cancer

9

What are the key clinical features of metastatic disease in the small bowel? 

  • Obstruction 
  • Bleeding

10

What are your investigations of choice for an adenocarcinoma? 

  • CT abdomen and pelvis
  • Endoscopy

11

What are your investigations of choice for a carcinoid tumour? 

  • Most are found incidentally at surgery for obstruction or appendectomy 
  • Chest thorax/abdo/pelvis CT
  • Consider small bowel enteroclysis to look for primary 
  • Elevated 5-HIAA (break down product of serotonin) in urine or increased 5-HT in blood
  • Radiolabelled octreotide or MIBG scans to locate tumour 

12

What are your investigations of choice for a lymphoma of the small bowel? 

  • CT abdo/pelvis

13

What are your investigations of choice for metastatic disease of the small bowel? 

  • CT abdo/pelvis

14

Outline brief plans for treatment of each of the four malignant pathologies the small intestine discussed so far. 

  • Adenocarcinoma 
    • Surgical resection and chemotherapy 
  • Carcinoid 
    • Surgical resection and chemotherapy 
    • Carcinoid syndrome treated witih steroids, histamine, octreotide
  • Lymphoma 
    • Low grade - chemotherapy with cyclophosphamide 
    • High grade - surgical resection, radiation 
    • Palliative - somatostatin and doxorubicin 
  • Metastatic 
    • Paliation 

15

Simply define a hernia. 

  • It is a fascial defect - in which there is a protrusion of a viscus into an area in which it is not normally contained. 

16

What are the risk factors for a hernia? 

  • Activities which increased intra-abdominal pressure
    • Obesity 
    • Chronic cough 
    • Pregnancy
    • Constipation 
    • Straining on urination or defecation 
    • Ascites 
    • Heavy lifting 
  • Congenital abnormality 
  • Previous hernia repair

17

What are the clinical features of a hernia? 

  • It is a mass of variable size
  • Tenderness worse at end of the day, relieved by supine position or with reduction 
  • Abdominal fullness, vomiting and constipation 
  • Transmits palpable impulse with coughing or straining 

18

Outline some investigations for a hernia. 

  • Physical examination usually sufficient 
  • Ultrasound 
    • With or without a CT 
      • A CT is usually required for obturator hernias, internal abdominal hernias and Spigelian femoral hernias in obese patients

19

What are the borders of Hesselbach's Triangle? 

  • Lateral - inferior epigastric artery 
  • Inferior - inguinal ligament
  • Medial - lateral margin of rectus sheath 

20

Outline a classification system for hernias. 

  • Complete
    • hernia sac and contents protrude through defect 
  • Incomplete
    • Partial protrusion through the defect
  • Internal hernia 
    • Sac herniating into or involving intra-abdominal structure 
  • External hernia 
    • Sac protrudes completely through the abdominal wall 
  • Strangulated hernia 
    • Vascular supply of protruded viscus is compromised ( ischemia) 
      • Requires emergency repair 
  • Incarcerated hernia 
    • Irreducible hernia, not necessarily strangulated 
  • Richter's hernia 
    • Only part of bowel circumference (usually anti-mesenteric border) is incarcerated or strangulated so may not be obstructed
      • A strangulated Richter's hernia may self-reduce and thus be overlooked, leaving a gangrenous segment at risk of perforation
  • Sliding hernia 
    • Part of wall of hernia formed by protruding viscus (usually cecum) 

21

What are the different anatomical types of hernias? 

  • Groin 
    • Indirect and direct inguinal, femoral 
    • Pantaloon - combined direct and indirect hernias - peritoneum draped over epigastric vessels 
  • Epigastric
    • Defect in linea alba above umbilicus
  • Incisional 
    • Ventral hernia at site of wound closure - may be secondary to wound infection 
  • Other 
    • Littre's (involving Meckel's diverticulum) 
    • Amyand's (containing appendix)
    • Lumbar
    • Obturator 
    • Parastomal 
    • Umbilical 
    • Spigelian (ventral hernia through linea semilunaris) 

22

What are the complications of hernias? 

  • Incarceration  - irreducible hernias 
  • Strangulation 
    • irreducible with resulting ischemia 
      • Small - new hernias more likely to strangulate 
      • Femoral >>, indirect iinguinal > direct inguinal 
      • Intense pain followed by tenderness 
      • Intestinal obstruction, gangrenous bowel and sepsis
      • Surgical emergency 

23

What treatment options are available for a hernia? 

  • Surgical treatment (herniorrhaphy) is only to prevent strangulation and evisceration for symptomatic relief, for cosmesis - if asymptomatic can delay surgery 
  • Repair may be done open or laproscopic and may use mesh for tension free closure 
  • Most repairs are now done using tension-free techniques - a plug in the hernial defect and a patch over it or patch alone 
  • Observation is acceptable for small asymptomatic inguinal hernias 

24

What are the postoperative complications for hernia repair? 

  • Recurrence 
    • Risk factors 
      • Age greater than 50
      • BM greater than 25
      • Poor pre-op functional status 
      • Associated medical conditions:
        • Type II DM
        • Hyperlipidemia 
        • Immunosuppression 
        • Any comorbid conditions increasing intra-abdominal pressure 
        • Less common with mesh/tension free repair 
  • Scrotal hematoma 
    • Painful scrotal swelling from compromised venous return of testes
    • Deep bleeding - may enter retroperitoneal space and not be initially apparent 
    • Difficulty voiding 
  • Nerve entrapment 
    • Ilioinguinal (causes numbness of inner thigh or lateral scrotum) 
    • Genital branch of genitofemoral (spermatic cord) 
  • Stenosis/occlusion of femoral vein 
    • Acute leg swelling
  • Ischaemic colitis 

25

What are the contents of the spermatic cord? 

  • Vas deferens
  • Testicular artery/veins 
  • Genital branch of gentiofemoral nerve 
  • Lymphatics 
  • Cremaster muscle 
  • Hernia sac

26

Describe the anatomical location of an inguinal hernia 

MD's Don't LIe

 

MD: Medial to: the inferior epigastric artery = Direct inguinal hernia 

LIe: Lateral to the inferior epigastric artery = Indirect inguinal hernia 

27

Describe the etiology of groin hernias. 

  • Direct inguinal 
    • Acquired weakness of trasvrsalis fascia 
    • Wear and tear 
    • Increased abdominal pressure 
  • Indirect inguinal 
    • Congenital persistence of processus vaginalis in 20% of adults 
  • Femoral 
    • Pregnancy - weakness of pelvic floor musculature 
    • Increased intra-abdominal pressure 

28

What is the anatomy of direct inguinal hernias? 

  • Through Hessellbach's triangle 
  • Medial to inferior epigastric artery - usually does not descend into scrotal sac 

29

What is the anatomy of an indirect inguinal hernia? 

  • Originates in deep inguinal ring 
  • Lateral to inferior epigastric artery 
  • Often descends into scrotal sac (or labia majora) 

30

What is the anatomy of a femoral hernia? 

  • Into femoral canal, below inguinal ligament but may override it 
  • Medial to femoral vein within femoral canal 

31

Describe the anatomy of the superficial inguinal ring.

  • Opening in external abdominal aponeurosis; palpable superior and lateral to pubic tubercle 
  • Medial border:
    • Medial crus of external abdominal aponeurosis 
  • Lateral border
    • Lateral crus of external oblique aponeurosis 
  • Roof
    • Intercrural fibres 

32

Describe the anatomy of the deep inguinal ring

  • Opening in transversalis fascia - palpable superior to mid-inguinal ligament 
  • Medial border:
    • Inferior epigastric vessels 
  • Superior-lateral border:
    • Internal oblique and transversus abdominis muscles 
  • Inferior:
    • Inguinal ligament 

33

Define the term ''bowel obstruction''

  • Partial or complete blockage of the bowel resulting in failure of intestinal contents to pass through the lumen 

34

What is the pathogenesis of bowel obstruction? 

  • Disruption of the normal flow of intestinal contents - proximal dilatation + distal decompression 
  • May tak 12-24 h to decompress, therefore passage of feces and flatus may occur after the onset of obstruction 
  • Bowel ischaemia may occur if blood supply is strangulated or bowel wall inflammation leads to venous congestion 
  • bowel wall edema and disrupton of normal bowel absorptive function - increased intraluminal fluid - transudative fluid loss into the peritoneal cavity - leading to electrolyte disturbances 

35

What are the clinical features of bowel obstruction? 

  • Must differentiate between obstruction and ileus - characterise obstruction as acute vs chronic, partial vs complete (constipation vs obstipation), small vs large bowel, strangulating vs non-strangulating, and with vs without perforation. 

36

What are the clinical features of a small bowel obstruction? 

  • Nausea, vomiting
    • Early, may be bilious 
  • Abdominal pain 
    • Colicky 
  • Constipation 
    • +
  • Other
    • May have visible peristalsis 
  • Bowel sounds 
    • Normal - increased
    • Absent if secondary ileus 
  • AXR findings 
    • Air-fluid levels 
    • 'Ladder' pattern plicae circularis 
    • Proximal distention (>3cm) with no colonic gas 

37

What are the clinical features of a large bowel obstruction? 

  • Nausea, vomiting
    • Late and may be feculent 
  • Abdominal pain 
    • Colicky 
  • Abdominal distention 
    • ++
  • Other
    • May present with visible peristalsis 
  • Bowel sounds 
    • Normal, increased (borborygmi) 
    • Absent if secondary ileus present 
  • AXR findings 
    • Air-fluid levels 
    • 'Picture frame' appearance 
    • Proximal distention and distal decompression 
    • No small bowel air if competent ileocecal valve 
    • Coffee bean sign 

38

What are the clinical features of a paralytic ileus? 

  • Nausea and vomiting 
    • Present 
  • Abdominal pain 
    • Minimal or absent 
  • Abdominal distention 
    • +
  • Constipation 
    • +
  • Bowel sounds 
    • Decreased or absent 
  • AXR findings 
    • Air throughout small bowel and colon 

39

What are the complications of total obstruction? 

 

  • Strangulating obstruction (10% of bowel obstructions) = surgical emergency 
    • Cramping pain turns to continuous ache, hematemesis, melena (if infarction)
    • Fever, leukocytosis and tachycardia 
    • Peritoneal signs, early shock 
  • Other 
    • Perforation - secondary to ischaemia and luminal distention 
    • Septicemia 
    • Hypovolemia (due to third spacing) 

40

What investigations will you consider in bowel obstruction? 

  • Radiological 
    • Upright CXR or left lateral decubitus (LLD) to rule out free air; usually seen under the right hemidiaphragm 
    • Abdominal x-ray (3 views) to determine SBO vs LBO vs ileus 
      • If ischaemc bowel look for:
        • free air 
        • pneumatosis 
        • thickened bowel wall 
        • air in portal vein 
        • dilated small and large bowels 
        • thickened or hose like haustra (normally finger like projections)
    • Other
      • Most used - CT provides information on level of obstruction, severity and cause 
        • important to r/o closed loop obstruction - especially in the elderly 
      • Less used - upper GI series/small bowel series for SBO (if no cause apparaent i.e. no pervious hernias or surgeries) 
      • If suspect LBO - consider a rectal water soluble enema rather than a barium enema (can thicken and cause complete obstruction) 
      • May consider ultrasound or MRI in pregnany patients 
  • Laboratory studies 
    • May be normal early in disease course 
    • BUN, creatinine, hematocrt (hemoconcentration) to assess degree of hydration 
    • fluid, electrolyte abnormalities 
    • amylase elevated
    • metabolic alkalosis due to frequent emesis 
    • if strangulation - leukocytosis with left shift, lactic acidosis, elevated LDH (late signs) 

41

What are the causes of SBO? 

SHAVING 

Stricture

Hernia

Adhesions

Volvulus 

Intussusception/IBD

Neoplasm 

Gallstones 

 

42

What is the management plan for bowel obstruction? 

  • Stabilize vitals, fluids and electrolyte resuscitation (with normal saline/Ringer's first, then with added potassium after fluid deficits are corrected) 
  • NG tube to relieve vomiting, prevent aspiration and decompress small bowel by prevention of further distention by swalloed air 
  • Foley catheter to monitor in and outs

43

What is the etiology of a small bowel obstruction? 

  • Intraluminal 
    • Intussuscpetion 
    • Gallstones 
  • Intramural 
    • Crohn's 
    • Radiation stricture 
    • Adenocarcinoma 
  • Extramural 
    • Adhesions 
    • Incarcerated hernia 
    • Peritoneal carcinomatosis 

44

What is the tratment of a small bowel obstruction? 

  • Consider whether complete or partial obstruction, ongoing or impending strangulation location and cause:
    • SBO with history of previous abdo/pelvic surgery - likely to resolve with conservative management - surgery if no resolution in 48-72 hours or complications 
    • Complete SBO, strangulation - urgent surgery after stabilizing patient with fluid resuscitation 
    • SBO with no previous surgery and no evidence of carcinomatosis - operate 
    • Trial of medical management may be indicated with Crohn's, recurrent SBO, carcinomatosis
      • NGT decompression 
      • GI rest
      • Serial abdominal exams 
    • Special case:
      • Early postoperative SBO (within 30 days of abdominal surgery) - prolonged trial of conservative therapy may be appropriate, surgery is reserved for complications such as strangulation 

 

45

What is the etiology of large bowel obstruction? 

  • Intraluminal 
    • constipation 
  • Intramural 
    • Adenocarcinoma 
    • Diverticultis 
    • IBD stricture 
    • Radiation stricture 
  • Extramural 
    • Volvulus 
    • Adhesions

46

What are the clinical features of a large bowel obstruction? 

  • Open loop (10-20%) (safer):
    • Incompetent ileocecal valve allows relief of colonic pressure as contents reflux into the ileum, therefore clinical presentation similar to SBO 
  • Closed loop (80-90%) (dangerous)
    • Competent ileocecal valve, resulting in proximal and distal occlusions 
    • Massive colonic distention 
      • Increased pressure in the cecum - leading to bowel ischaemia - necrosis and ultimately perforation

47

What is the treatment of a LBO? 

  • Surgical correction of obstruction (usually requires resection and temporary diverting colostomy)
  • Volvulus requires sigmoidoscopic or endoscopic decompression followed by operative reduction if unsuccessful 
    • If successful, consider sigmoid resection on same admission 
  • Cecal volvulus can be a true volvulus or a cecal 'bascule' - both need surgical treatment 

 

48

What is the defintion of a colonic pseudo-obstruction? 

  • Condition with symptoms of intestinal blockage without any physical signs of blockage 

49

What is the differential diagnosis of a colonic pseudo-obstruction? 

  • Acute 
    • toxic megacolon 
    • trauama 
    • postoperative (especially post orthopedic procedures with prolonged immoblization) 
    • neurological disease
    • retroperitnoeal disease 
    • medications (narcotic and psychiatric)
  • Chronic 
    • Neurologic disease (enteric, central, peripheral nervous system)
    • Scleroderma 

50

What is the pathogenesis of toxic megacolon? 

  • Extension of inflammation into smooth muscle layer causing paralysis 
  • Damage to myenteric plexus and electrolyte abnormalities are not consistently found

51

What is the etiology of toxic megacolon? 

  • IBD
  • Infectious colitis 
    • bacterial (c.diff, salmonella, shigella, campylobacter) 
    • viral (cytomegalovirus)
    • parasitic (E.histolytica) 
  • Volvulus
  • Diverticulitis 
  • Ischaemic colitis 
  • Obstructing colon cancer are rare causes

52

What are the clinical features of toxic megacolon? 

• infectious colitis usually present for >1 wk before colonic dilatation 
• diarrhea ± blood (but improvement of diarrhea may portend onset of megacolon) 
• abdominal distention, tenderness, ± local/general peritoneal signs (suggest perforation) 
• triggers: hypokalemia, constipating agents (opioids, antidepressants, loperamide, 
anticholinergics), barium enema, colonoscopy

53

What is the diagnostic criteria for toxic megacolon? 

  • Must have both colitis and sytemic manifestations for diagnosis 
  • Radiologic evidence of dilated colon 
  • Three of:
    • Fever
    • Hear rate (greater than 120) 
    • WBC (greater than 10.5) 
    • Anaemia 
  • One of:
    • Fluid and electrolyte disturbances
    • Hypotension 
    • Altered LOC 
  •  

54

What are the investigations that form part of the work up for toxic megacolon? 

  • FBC
    • Look for leukocytosis
    • Anaemia from bloody diarrhea 
    • Electrolytes 
    • Elevated CRP and ESR
  • ABG
    • Metabolic alkalosis - due to volume contraction and hypokalemia 
    • Hypoalbuminaemia 
    • Although these are late findings 
  • AXR
    • Dilated colon (greater than 6cm) (right>transverse>left), loss of haustra 
  • CT
    • Useful in assessing underlying disease 

 

55

What is your management plan for a patient with toxic megacolon? 

  • NBM
  • NG Tube
  • Stop constipating agents 
  • Correct fluid and electrolyte abnormalities and transfusion 
  • Serial AXRs
  • Broad-spectrum antibiotics
    • reduce sepsis 
    • anticipate perforation 
  • Aggressive treatment of underlying disease 
    • (steroids in IBD or metronidazole for C.difficile) 

56

What are the indications for surgery in a patient with toxic megacolon? 

  • Worsening or persisting toxicity or dilatation after 48-72 hours
  • Severe haemorrhage and perforation 
  • High lactate and WBC specifically for C.difficile 

57

What is the surgical procedure indicated for toxic megacolon? 

  • Subtotal colectomy and end ileostomy (may be temporary, with second operation for re-anastamosis later) 

58

Briefly, what is the pathogenesis for paralytic ileus? 

  • Temporary paralysis of the myenteric plexus

59

What are the associations with paralytic ileus? 

  • Postoperative 
  • Intra-abdominal sepsis 
  • Medications 
    • Opiates
    • Anesthetics 
    • Psychotropics 
  • Electrolyte disturbances 
    • Sodium 
    • Potassium 
    • Calcium 
  • Microbiology
    • C.difficile 
  • Inactivity 

60

What is the treatment for paralytic ileus? 

  • NG decompression 
  • NBM
  • Fluid resuscitation 
  • Correct causative abnormalities 
    • Sepsis
    • Medications
    • Electrolytes 
  • Consider TPN for prolonged ileus 
  • Post-operatively - gastric and small bowel motility returns by 24-48 hours, colonic motility by day 3-5. 

61

What is the etiology of intestinal ischaemia? 

  • Acute 
    • Arterio-occlusive mesenteric ischemia (AOMI)
      • thrombotic
      • embolic 
      • extrinsic compression (e.g. strangulating hernia) 
    • Non-occlusive mesenteric ischaemia (NOMI)
      • mesenteric vasoconstriction secondary to systemic hypoperfusion (preserves supply to vital organs)
    • Mesenteric venous thrombosis (MVT)
      • consider hypercoagulable state (ruling out malignancy) 
      • DVT (prevents venous outflow) 
  • Chronic 
    • Usually due to atherosclerotic disease - look for CVD risk factors 

62

What are the clinical features of intestinal ischaemia? 

  • Acute
    • Severe abdominal pain out of proportion to physical findings 
    • Vomiting 
    • Bloody diarrhea 
    • Bloating
    • Minimal peritoneal signs early in course
    • Hypotensive shock and sepsis 
  • Chronic 
    • Postprandial pain 
    • Fear of eating
    • Weight loss 
  • Common sites:
    • Superior mesenteric artery (SMA) supplied territory 
  • 'Watershed' areas of the colon:
    • splenic flexure 
    • left colon 
    • sigmoid colon 

63

What are the investigations to be considered when diagnosing intestinal ischaemia? 

  • FBC
    • Leukocytosis 
  • Bloods
    • Lactic acidosis (late finding)
    • Amylase 
    • LDH
    • CK
    • ALP 
    • Hypercoagulability workup if suspect venous thrombosis 
  • AXR
    • Portal venous gas
    • Intestinal pneumatosis 
    • Free air, if perforation 
  • Contrast CT
    • thickened bowel wall 
    • luminal dilatation 
    • SMA or SMV thrombus, mesenteric/portal venous gas
    • pneumatosis 
  • CT angiography is the gold standard for acute arterial ischaemia 

64

What is your management and treatment plan for intestinal ischaemia? 

  • Fluid resuscitation
  • Correct metabolic acidosis
  • NBM
  • NG decompression of stomach 
  • Prophylactic broad spectrum antibiotics, avoid vasoconstrictors and digitalis 
  • Exploratory laparotomy 
  • Angiogram, embolectomy/thrombectomy, bypass graft and mesentric endarterectomy, anticoagulation therapy, percutaneous transluminal angioplasty with or without stent 
  • Segmental resection of necrotic intestine:
    • assess extent of viability; if extent of bowel viability is uncertain, a second look laparotomy 12-24 hours later is mandatory. 

65

What is the modified Alvarado score for acute appendicitis? 

1 point per:


• Migratory right Iliac fossa pain
(1 point)
• Anorexia (1 point)
• Nausea/vomiting (1 point)


• Tenderness in right Iliac fossa
(2 points)


• Rebound tenderness in right Iliac
fossa (1 point)


• Fever >37.5°C (1 point)


• Leukocytosis (2 points)


• 0-3 = low risk, discharge to return if
no improvement
• 4-6 = moderate risk, admit, observe,
repeat examinations


• Male 7-9 = appendectomy
• Female (not pregnant) 7-9 = diagnostic
laparoscopy ± appendectomy

66

What is McBurney's sign? 

Tenderness 1/3 the distance from the ASIS to the umbilicus on the right side 

67

What is the pathogensis of appendicitis? 

  • Luminal obstruction - bacterial overgrowth - inflammation/swellling - increased pressure - localised ischaemia - gangrene/perforation - localised abscess (walled off by omentum) or peritonitis 

 

68

What is the etiology of appendicitis? 

  • Children or young adult:
    • Hyperplasia of lymphoid follicces 
    • Initiated by infection 
  • Adult 
    • Fibrosis/stricture
    • Fecolith 
    • Obstructing neoplasm 
  • Other causes:
    • parasites and foreign body 

69

What are the clinical features of appendicitis? 

  • Most reliable feature is progression of signs and symptoms
  • Low grade fever, rises with perforation 
  • Abdominal pain then anorexia, nausea and vomiting 
  • Classic pattern:
    • Pain initially periumbilical; constant, dull, poorly localised, then well localised pain over McBurney's point 
      • Due to progression of disease from visceral irritation (causing referred pain from structures of the embryologic midgut - including the appendix) to irritation of parietal structures 
      • McBurney's sign 
  • Signs:
    • Inferior appendix - McBurney's sign, Rosving's sign (palpation presure to left abdomen causes McBurney's point tenderness) 
    • Retrocecal appendix:
      • Psoas sign (pain on flexion of hip against resistance or passive hyperextension of hip) 
    • Pelvic appendix:
      • Obturator sign (flexion then external or internal rotation about right hip causes pain) 
  • Complications
    • Perforation 
    • Abscess, phlegmon

70

What investigations would you order for a case of appendicitis? 

  • Labs/Bloods:
    • Mild leukocytosis with left shift (normal WBC counts)
    • Higher leukoctye count with perforation 
    • beta hCG to rule out pregnancy 
    • urinalysis 
  • Imaging:
    • upright CXR, AXR - usually nonspecific - free air if perforated (rarely), calcified fecolith, loss of psoas shadow, RLQ ileus 
    • Ultrasound - may visualise appendix but also helps rule out gynecological causes
    • CT scan - thick wall, appendicolith, inflammatory changes

71

What is your treatment plan for appendicitis? 

  • Hydration and correct electrolyte abnormalities 
  • Surgery (gold standard, 20% mortality with perforation especially in the elderly) + antibiotic coverage 
  • If localised abscess (palpable masses or large phlegmon on imaging and often pain >4-5 days)
  • consider radiological drainage and antibiotics x 14 days + or - interval appendectomy in 6 weeks 
  • Appendectomy
    • Laparoscopic or open 
    • Complications
      • Spillage of bowel contents
      • Pelvic abscess
      • Enterocutaneous fistula 
    • Perioperative antibiotics
      • cefazolin + metronidazole (no post-op antibiotics unless perforated) 
      • other choices - 2nd or 3rd generation cephalosporin for aerobic gut organisms 
    • Colonoscopy in the eldery to rule out other etiology (neoplasm) 

72

Compare laparoscopic and open appendectomy

  • Laparoscopic
    • Wound infection less likely 
    • Intra-abdominal abscesses 2 times more likely 
    • Reduced pain on post-operative day 1
    • Reduced hospital stay 
    • Sooner return to normal activity, work and sport
    • Costs outside outside hospital are reduced
  • Open
    • Shorter duration of surgery 
    • Lower operation costs 

73

What is: 

  • A diverticulum 
  • Diverticulosis 
  • Diverticulitis 
  • True diverticuli
  • False diverticuli 

  • Abnormal sac like protrusion from the wall of a hollow organ 
  • Presence of multiple diverticula 
  • Inflammation of diverticula 
  • Contain all layers of the colonic wall, often right sided 
  • False diverticuli - contain mucosa and submucosa - often left sided

74

What is the pathogenesis of diverticulosis? 

  • Risk factors:
    • Lifestyle 
      • Low fibre diet
        • Predispose to motility abnormalities and higher intraluminal pressure, inactivity and obesity 
        • muscle wall weakness from aging and illness (Ehler-Danlos, Marfan's) 
      • high intraluminal pressure causes outpouching to occur at point of greatest weakness, most commonly where vasa recta penetrates the circular muscle layer - therefore increasing the risk of haemorrhage. 

75

What are the clinical features of diverticulosis? 

  • Uncomplicated diverticulosis - asymptomatic 
  • Episodic abdominal pain (often LLQ), bloating, flatulence, constipation and diarrhea 
  • Absence of fever and leukocytosis 
  • No physical exam findings or poorly controlled LLQ tenderness 
  • Complicatoins 
    • Diverticulitis 
      • 25% of which are complicated (i.e. abscess, obstruction, perforation and fistula) 
      • Bleeding (5-15%) - painless rectal bleeding, 30-50% of massive lower GI bleeds
      • Diverticular colitis (rare) - diarrhea, hematochezia, tenesmus, abdominal pain 

76

What is the treatment for diverticulosis? 

  • Uncomplicated diverticulosis: high fibre and education 
  • Diverticular bleed 
    • Initially work up and treat as any lower GI bleed 
    • If haemorrhage does not stop, resect involved region 

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What is the pathogenesis of diverticulitis ? 

  • erosion of the wall by increased intraluminal pressure or inspissated food particles leading to...
  • inflammation and focal necrosis gmicro or macroscopic perforation usually mild inflammation with perforation walled off by pericolic fat and mesentery; abscess, 
  • fistula or obstruction can ensue 
  • poor containment results in free perforation and peritonitis 

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What are the clinical features of diverticulitis? 

  • depend on severity of inflammation and whether or not complications are present; hence ranges from asymptomatic to generalized peritonitis 
  •  LLQ pain/tenderness (2/3 of patients) often for several days before admission 
  • constipation, diarrhea, nausea, vomiting, urinary symptoms (with adjacent inflammation)
  • complications (25% of cases):
    • ƒabscess: palpable tender abdominal mass 
    • ƒfistula: colovesical (most common), coloenteric, colovaginal, colocutaneous 
    • ƒcolonic obstruction: due to scarring from repeated inflammation 
    • ƒperforation: generalized peritonitis (feculent vs. purulent) 
      • Šrecurrent attacks rarely lead to peritonitis

• low-grade fever, mild leukocytosis common, 
• occult or gross blood in stool rarely coexist with acute diverticulitis

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What are the investigations for diverticulitis? 

  • AXR, upright CXR
    • Localized diverticulitis (ileus, thickened wall, SBO, partial colonic obstruction)
    • Free air may be seen in 30% with perforation and generalized peritonitis 
  • CT scan (test of choice) - very useful for assessment of severity and prognosis
    • 97%, sensitive; 99% specific 
    • Increased soft tissue density within pericolic fat secondary to inflammation, diverticula secondary to inflammation, bowel wall thickening, soft tissue mass (pericolic fluid, abscesses), fistula 
    • 10% of diverticulitis cannot be distinguished from carcinoma 
  • Hypaque (water soluble) enema - safe (under low pressure)
    • Saw tooth pattern (colonic spasm) 
    • May show site of perforation, abscess cavities or sinus tracts, fistulas 
  • Elective evaluations: establish extent of disease and rule out other diagnoses (polyps, malignancies) after resolution of acute episode 
    • Colonoscopy or barium enema and flexible sigmoidoscopy 

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What are your treatment options for diverticulosis? 

  • Uncomplicated:
    • Conservative management 
  • Outpatient:
    • Clear fluids only until improvement and antibiotics (e.g. ciproflxacin and metronidazole) 7-10 days to cover gram negative rods and anaerobes (e.g. B fragilis) 
  • Hospitalize: if severe presentation, inability to tolerate oral intake, significant comorbidities, fail to improve outpatient management 
  • Treat with NBM, IV fluids, IV antibiotics, (e.g. IV ceftriaxone + metronidazole, ampicillin, gentamicin)
  • Indications for surgery:
    • Unstable patient with peritonitis 
    • Hinchey stage 3-4
    • After 1 attack if:
      • Immunosuppressed
      • Abscess needing percutaneous