Ch. 23 LLQ Pain and Fever Flashcards
Where in the colon do diverticula occur most frequently? Which diverticula are more prone to infection? Bleeding?
Sigmoid colon
Diverticula in L or sigmoid colon = more likely to become infected
Diverticula in R colon = more likely to bleed
Do diverticula occur in the rectum? Why/Why Not?
Rectal diverticula = extremely rare
Hypothesized that they almost never occur because the taenia coli, the longitudinal bands of smooth muscle along the colon, coalesce into a circumferential band around the rectum, thereby eliminating points of weakness that precede a diverticulum
What two diagnostic studies are contraindicated in the acute setting of suspected diverticulitis and why?
Barium enema and colonoscopy
In an inflamed colon, there is an increased risk of new perforation or exacerbation of existing perforation
Mgmt of Uncomplicated Diverticulitis
- No SIRS
- w/ SIRS
- Fails to improve with IV abx
Mgmt of Complicated Diverticulitis
Complication:
Free perforation with diffuse peritonitis
LBO
Large (>4 cm) localized abscess
Small (<4 cm) localized abscess
Colovesical fistula
What structure is at risk of damage or complete transection during sigmoid colonic resection?
Ureters
A 53 y/o man presents to ER with LLQ pain, fever, vomiting. CT scan of abdomen and pelvis reveals a thickened sigmoid colon with inflamed diverticula and a 7-cm by 8-cm rim-enhancing fluid collection in the pelvis. After percutaneous drainage and treatment with abx, the pain and fluid collection resolve. He returns as an outpatient to clinic 1 mo later. He undergoes a colonoscopy, which demonstrates only diverticula in the sigmoid colon. What is the most appropriate next step in this pt’s mgmt?
Sigmoid resection + primary anastomosis
Diverticular abscesses are treated with percutaneous drainage initially followed by definitive resectional therapy.
Perforated diverticulitis is typically treated with either the Hartmann procedure (sigmoid resection with end colostomy and rectal stump) or sigmoid resection, anastomosis, and diverting loop ileostomy.
A 63-year-old woman comes to the emergency department because of a 2-day history of fever and worsening lower abdominal pain. She has not had a bowel movement in 3 days. There is no history of nausea or vomiting. The patient had 2 similar episodes during the past year that were diagnosed as diverticulitis, and she was treated with antibiotics. She has a 10-year history of intermittent constipation and diarrhea that resolve with nonprescription medications. Her primary care physician has treated her for urinary tract infections 3 times during the last 2 months. The patient had a hysterectomy 12 years ago for uterine fibroids. Her brother underwent chemotherapy for colon carcinoma, and her paternal grandfather died of the disease.
Which of the following items elicited in the patient’s history would make you suspect complicated diverticulitis?
a. Fever and worsening abdominal pain
b. History of no bowel movements in 3 days
c. History of alternating constipation and diarrhea
d. Three urinary tract infections in the last 2 months
e. Family history of colon carcinoma
d. Three UTIs in the last 2 months
Complicated diverticulitis includes perforation, abscess, obstruction or fistula. Fever and worsening abdominal pain are common symptoms of diverticulitis that do not necessarily indicate a complicated course. The family history of colon cancer and the history of alternating constipation and diarrhea, while concerning, again do not point to a complicated course. The history of no bowel movements in 3 days is still within the normal range and does not indicate obstruction. The frequent recent UTI’s may indicate a colovescicle fistula and should be investigated further.
A previously healthy 56-year-old man presents to the emergency department with a 12-hour history of fever and increasingly severe left-sided abdominal pain. He has not had nausea, vomiting, or diarrhea. He takes no medications.
On physical examination, temperature is 101.5°F (38.6°C), pulse is 90/min, respirations are 16/min, and blood pressure is 130/80 mm Hg. There is focal tenderness with guarding on palpation over the left lower abdomen. The remainder of the physical examination is unremarkable.
Laboratory studies are remarkable for a leukocyte count of 12,200 cells/mm3.
Which of the following is the most appropriate next step in diagnosis?
a. Barium enema
b. Colonoscopy
c. Laparoscopy
d. Supine and upright x-rays of the abdomen
e. Computed tomography of the abdomen
e. CT
The best answer is computed tomography of the abdomen. The question describes uncomplicated diverticulitis. An abdominal X-ray series may identify free air (and therefore a perforation), but the absence of peritonitis makes this unlikely. It will not confirm diverticulitis nor identify other problems, such as an abscess. A barium enema or colonoscopy are contraindicated in the acute setting because of the increased risk of perforation with the increased intraluminal pressure. These should only be done in about 2 months after recovery from the acute episode of diverticulitis. Laparoscopy is invasive and unnecessary. A CT is the best option to confirm the diagnosis and to rule out an abscess, which is the most likely complication in this scenario.
A 62-year-old woman with a 6-year history of diverticulosis presents to the emergency department with abdominal pain that began 3 days ago and is getting worse.
On physical examination, temperature is 98.6°F (37.0°C), pulse is 110/min, respirations are 16/min, and blood pressure is 142/84 mm Hg. She appears nontoxic, although she asks if she can forego an abdominal examination because “it really hurt” when the emergency department attending physician examined her.
Which of the following physical examination findings would be most concerning for the subsequent management of this patient?
a. Pain on deep palpation of all 4 quadrants
b. The patient winces in pain when her bed is accidentally bumped
c. The patient has stool in the rectal volt.
d. Absence of bowel sounds upon auscultation for 10 seconds
e. No pain on percussion at the costovertebral angle
b. The patient winces in pain when her bed is accidentally bumped
The best answer is The patient winces in pain when her bed is accidentally bumped, because it indicates peritonitis. This could indicate a free perforation which would require immediate surgery. Decreased bowel sounds could indicate an ileus. Obstruction would present with no bowel sounds or high pitched bowel sounds along with nausea, vomiting and distension. Pain on deep palpation does not necessarily mean peritonitis and is less concerning.
A 72-year-old woman presents to the emergency department with a 4-hour history of intense abdominal pain preceded by 2 days of vague left lower quadrant pain and nausea. She has no history of similar episodes. Her medical history is remarkable for atrial fibrillation, hypertension, and type 2 diabetes mellitus. Her current medications are amiodarone, losartan, hydrochlorothiazide, and enalapril. She has no history of previous surgeries.
On physical examination, temperature is 101.0°F (38.4°C), pulse is 125/min and irregular, respirations are 20/min, and blood pressure is 132/86 mm Hg. Pulse oximetry shows an oxygen saturation of 99%. The abdomen is exquisitely tender to palpation of the left and right lower quadrants; a mass is appreciated in the left lower quadrant, and palpation elicits abdominal guarding. Intravenous fluids are begun, and the patient is instructed to receive nothing by mouth. Results of laboratory studies are pending.
Which of the following laboratory results would necessitate the greatest change in the subsequent management of this patient’s condition?
a. Urinalysis showing 10 RBCs, 2 WBCs/hpf, leukocyte esterase positive, nitrite positive
b. Hemoglobin of 10.2 g/dL (normal: 12–15 g/dL)
c. Leukocyte count: 14,000/mm3 (normal: 4000–11,000/mm3)
d. Serum creatinine of 2.3 mg/dL (normal: <1.4 mg/dL)
e. C-reactive protein of 42 mg/L (normal: <5 mg/L)
a. Urinalysis showing 10 RBCs, 2 WBCs/hpf, leukocyte esterase positive, nitrite positive
Elevated leukocyte count and C-reactive protein merely confirm that the patient has an infection. An elevated creatinine is unhelpful without knowing her baseline. If it is elevated from her baseline, it would be consistent with sepsis and hypovolemia. This would be treated with fluids, which is already being done. The hemoglobin, while low, would not necessitate any active intervention at this time. The positive urinalysis indicates that there is a urinary tract infection requiring antibiotics. It also may indicate a colovescicle fistula and should be investigated further when the patient is stabilized.
