EOR GI part 7- diverticular dz, volvulus Flashcards
Diverticulosis
Condition in which diverticula can be found within the colon, especially the sigmoid; diverticula are actually false diverticula in that only mucosa and submucosa herniate through the bowel musculature; tree diverticula involve all layers of the bowel wall and are rare in the colon
Pathophys of diverticulosis
Weakness in the bowel wall develops at points where nutrient blood vessels enter between antimesenteric and mesenteric teniae; increased intraluminal pressures then cause herniation through these areas
What is the MC site of diverticulosis?
95% of people with diverticulosis have sigmoid colon involvement
Who is at risk for diverticulosis?
People with low-fiber diets
Chronic constipation
Pos FHx
Incidence increases with age
What are the sx/complications of diverticulosis?
Bleeding: may be massive
Diverticulitis, asymptomatic (80% of cases)
What is the diagnostic approach for bleeding in diverticulosis?
Without signs of inflammation: colonoscopy
What is the diagnostic approach for pain and signs of inflammation in diverticulosis?
Abdominal/pelvic CT scan
What is the tx of diverticulosis?
High-fiber diet is recommended
What are the indications for operation with diverticulosis?
Complications of diverticulitis Recurrent episodes Hemorrhage Suspected carcinoma Prolonged sx Abscess not drainable by percutaneous approach
When is it safe to get a colonoscopy or barium enema/sigmoidoscopy for diverticulosis?
D/t risk of perforation, this is performed 6 wks after inflammation resolves to r/o colon CA
Diverticulitis
Infection or perforation of a diverticulum
Pathophys of diverticulitis
Obstruction of diverticulum by a fecalith leading to inflammation and microproliferation
S/sx of diverticulitis
LLQ pain (crampy or steady) Change in bowel habits Fever Chills Anorexia LLQ mass N/V Dysuria
What are the associated lab findings of diverticulitis?
Increased WBCs
What are the associated radiographic findings of diverticulitis?
On X-ray: Ileus Partially obstructed colon Air-fluid levels Free air if perforated On abdominal/pelvic CT scan: Swollen, edematous bowel wall, particularly helpful in diagnosing an abscess
What are the associated barium enema findings with diverticulitis?
Barium enema should be avoided in acute cases?
Is colonoscopy safe in an acute setting with diverticulitis?
No, there is increased risk of perforation
What are the possible complications of diverticulitis?
Abscess Diffuse peritonitis Fistula Obstruction Perforation Stricture
What is the MC fistula with diverticulitis?
Colovesical fistula (to bladder)
What is the best test for diverticulitis?
CT scan
What is the initial therapy for diverticulitis?
IVF
NPO
Broad spectrum abx with anaerobic coverage
NG suction (as needed for emesis/ileus)
When is surgery warranted for diverticulitis?
Obstruction
Fistula
Free perforation
Abscess not amenable to percutaneous drainage
Sepsis
Deterioration with initial conservative tx
What are indications for elective resection in diverticulitis?
Case by case decisions, but usually after two episodes of diverticulitis
Should be considered after the first episode in a young, diabetic, or immunosuppressed pt or to r/o CA
What surgery is usually performed ELECTIVELY for recurrent bouts of diverticulitis?
One-stage operation: resection of involved segment and primary anastomosis (with preop bowel prep)
What type of surgery is usually performed for an acute case of diverticulitis with a complication?
Hartmann’s procedure: resection of involved segment with an end colostomy and stapled rectal stump
Resection, primary anastomosis loop ileostomy
What is the tx of diverticular abscess?
Percutaneous drainage
If abscess is not amenable to percutaneous drainage, then surgical approach for drainage is necessary
How common is massive lower GI bleeding with diverticulitis?
Very rare
Seen with diverticulosis
What are the MC causes of massive lower GI bleeding in adults?
Diverticulosis (esp right-sided)
Vascular ectasia
What must you r/o in any pt with diverticulitis/diverticulosis?
Colon CA
What is the most common type of colonic volvulus?
Sigmoid volvulus
What are the etiologic factors of a sigmoid volvulus?
High-residue diet resulting in bulky stools and tortuous, elongated colon
Chronic constipation
Laxative abuse
Pregnancy
Seen most commonly in bedridden elderly or institutionalized pts, many of whom have hx of prior abdominal surgery or distal colonic obstruction
S/sx of sigmoid volvulus
Acute abdominal pain Progressive abdominal distention Anorexia Obstipation Cramps N/V
What findings are evident on abdominal plain film for sigmoid volvulus?
Distended loop of sigmoid colon, often in the classic “bent inner tube” or “omega” sign with the loop aiming toward the RUQ
What are the signs of necrotic bowel in colonic volvulus?
Free air
Pneumatosis (air in bowel wall)
How is the dx of sigmoid volvulus made?
CT scan
Sigmoidoscopy
Radiographic exam with Gastrografin enema
Under what conditions is Gastrografin enema useful for sigmoid volvulus?
If sigmoidoscopy and plain films fail to confirm the dx
Bird’s beak is pathognomonic seen on enema contrast study as the contrast comes to a sharp end
What are the signs of strangulation in sigmoid volvulus?
Discolored or hemorrhagic mucosa on sigmoidoscopy
Bloody fluid in the rectum
Frank ulceration or necrosis at the point of the twist
Peritoneal signs
Fever
Hypotension
Increased WBCs
What is the initial tx for sigmoid volvulus?
Nonoperative
What are the indications for surgery for a sigmoid volvulus?
Emergently if strangulation is suspected or nonop reduction unsuccessful
Most pts should undergo resection during same hospitalization of redundant sigmoid after successful nonop reduction because of high recurrence rate
What is a cecal “bascule” volvulus?
Instead of the more common axial twist, the cecum folds upward (lies on the ascending colon)
What is the etiology of cecal volvulus?
Idiopathic
Poor fixation of the right colon
Many pts have hx of abdominal surgery
What are the s/sx of cecal volvulus?
Acute onset of abdominal or colicky pain beginning in the RLQ and progressing to a constant pain
Vomiting
Obstipation
Abdominal distention
SBO
Many pts will have had previous similar episodes
How is the dx made of cecal volvulus?
Abd plain film: dilated, ovoid colon with large air/fluid level in the RLQ often forming the classic “coffee bean” sign with the apex aiming toward the epigastrium or LUQ (must r/o gastric dilation with NG aspiration)
What diagnostic studies should be performed for a cecal volvulus?
Water-soluble contrast study (Gastrografin) if dx cannot be made by AXR, CT
What is the tx for cecal volvulus?
Emergent surgery
Right colectomy with primary anastomosis or ileostomy and mucous fistula (primary anastomosis may be performed in stable pts)
What are the major differences in the EMERGENT management of cecal volvulus versus sigmoid?
Pts with cecal volvulus require surgical reduction, whereas the vast majority of pts with sigmoid volvulus undergo initial endoscopic reduction of the twist
