To operate or not to operate?

Case presentation

● GP referral to ED, BIBA.

● PC: Collapse and a fall at home. Had painful right chest wall She was unable to recall the event, Had no dizziness, headache, vomiting.

• PMH : 1. A.Fibrillation 2. Parkinsons 3. Hypertension 4. IHD 5. Hx of hysterectomy • Medications : Warfarin, Dilzem, Bumex

• Allergies: Penicillin

• Social Hx: lives alone , no home help.

O/E

• GCS 15/15, PEARL

• BP 147/90, Spo2 95%, HR 77, RR 19, Temp 36 C

• Occipital scalp hematoma with sutured laceration.

• CVS: irregular heart rate.

• Chest: Bilateral air entry with wheezing and

• Abdomen : soft, non tender

Blood investigations

● Haemoglobin 12.9 g/dl

● White Cell Count 12.3 x10^9/l

● CRP 3.8 mg/l

● INR 2.2

● U&E (N)

● LFT (N)

● Troponin I * 0.085 ng/ml ( <0.035 ) (>0.1 is positive) (0.035 -0.1= equivocal)

● ECG: nil acute.

Plan

• Admitted under the medical care.

2 days later

● developed sudden abdominal pain with vomiting.

Surgical consult

● O/E: BP 95/52, HR 78, Temp 36, SpO2 96% Distended Abdomen, Generalised tenderness with central guarding.

Repeat bloods

● White Cell Count 3.3 x10^9/l● CRP 61.6 mg/l● Urea * 20.1 mmol/l● Creatinine * 161 umol/l ● Lactate 2.40 mmol/l

Provisional surgical diagnosis :

● Acute abdomen

?? Ischaemic bowel

● What would you do??

Patient & Family

● The condition explained and discussed with the patient and family, including the high mortality associated with surgery in her case.

● Decision was taken to go ahead and operate.

Intra-operative details

● Generalized purulent peritonitis

● Thickened loop of small bowel (mid ileum) with few diverticula, one with sealed perforation. Scattered diverticula in rest of ileum.

● Multiple colon diverticula – with no complication.

Procedure

• Thickened loop of small bowel was resected with primary side to side anastomosis done.

● General peritoneal lavage.

● Pelvic drain.

Small bowel diverticula

Overview

● Small bowel diverticula occur most frequently in the duodenum where they are usually asymptomatic.

● In one retrospective review of 208 patients, diverticula were located in

duodenum jejunum or ileum in

all three segments

79 %(complications rate 13%)

18 %(complications rate 46 %)

3 %

Pathophysiology

● The cause of this condition is not known.

● It is believed to develop as the result of abnormalities in - peristalsis,

- intestinal dyskinesis, and - high segmental intraluminal pressures.

• The resulting diverticula emerge on the mesenteric border.

Classification

● Intraluminal or extraluminal.

● Intraluminal diverticula and Meckel diverticulum are congenital.

● Extraluminal diverticula

Presentation

● Usually asymptomatic.

● Presents with comlications: - Diverticular pain - Bleeding - Diverticulitis - Intestinal obstruction - Perforation and localized abscess - Malabsorption - Anemia - Biliary tract disease - Volvulus - Intestinal obstruction - Enteroliths - Intestinal obstruction - Bacterial overgrowth - Flatulence

Duodenal diverticula:

● These vary from a few millimeters to several centimeters and may be multiple.

● Approximately 75% occur within 2 cm of the ampulla of Vater.

● It is associated with increased incidence of biliary stones, pancreatitis, and biliary and pancreatic anomalies.

● Incidence increases with age.

● 50% of cases have associated colonic pseudodiverticulosis.

Jejunoileal diverticula:

● Duodenal and Meckel diverticulum excluded, small bowel diverticula are most common in the proximal jejunum.

● They usually are multiple and vary from a few millimeters to 10 cm.

● located on the mesenteric border within the leaves of the mesentery.

● are frequently associated with small intestine motility disorders,

● Hemorrhage and pancreaticobiliary disease are the most common complications of duodenal diverticulum,

● Diverticulitis and perforation are more common with jejunoileal diverticula.

Intraluminal diverticula:

● These are congenital diverticula resulting from defective recanalization of duodenal lumen during fetal development.

● These structures are believed to start as a fenestrated diaphragm that, over time, transforms into diverticulum as a result of peristalsis.

● It occurs singly and has duodenal mucosa on both sides. Intraluminal diverticula are usually located in the second part of the duodenum and can manifest at any age.

Risk factors to acquired pseudodiverticula:

● Low-fiber diet● High-fat diet● Advancing age• Heredity: No evidence indicates that it is. • Systemic sclerosis● Visceral myopathy● Visceral neuropathy

Investigations

● Lab tests: limited value

● Radiological.

● Endoscopy.

Managing SB diverticular Disease

● Medical /conservative : abdo pain, bloating, malabsoption

● Consultation to gastroenterologist/surgeon

● Diagnostic and therapeutic endoscopy

● Surgical : bleeding, perforation, obstruction, pseudoobstruction, fistula (rare)

● Diet

References

● Emedicine.com● Uptodate● Butler et al.Journal of Medical Case Reports 2010

● Thank you..