Surgery Case Surgery Case PresentationPresentation

By: Alaa TehraniBy: Alaa Tehrani

Chief Complaint:Chief Complaint:

“ “ I have been bleeding I have been bleeding heavy from below for about heavy from below for about 5 days”.5 days”.

History of Present Illness:History of Present Illness:

A 73 year old female with a PMH of A 73 year old female with a PMH of HTN, diverticulosis, and colon polyps HTN, diverticulosis, and colon polyps presented to the ER at 10:00 presented to the ER at 10:00 p.m.with a c/o of painless rectal p.m.with a c/o of painless rectal bleeding starting 5 days ago, on and bleeding starting 5 days ago, on and off. Patient stated that her clothes off. Patient stated that her clothes were soaked with blood. She were soaked with blood. She admitted to noticing bright red blood admitted to noticing bright red blood in her stool.in her stool.

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h/o dizziness, lethargy, and h/o dizziness, lethargy, and lightheadednesslightheadedness

No h/o abdominal painNo h/o abdominal pain No nausea or vomitingNo nausea or vomiting No h/o SOB, CP, palpitationsNo h/o SOB, CP, palpitations

Past Medical History:Past Medical History:

HTNHTN One year ago- One year ago- Diverticulosis-Diverticulosis- no no

surgical Tx.surgical Tx. seven years ago- seven years ago- Polyps, bleedingPolyps, bleeding- -

received blood transfusion.received blood transfusion. No PSHNo PSH

Other Information:Other Information:

Allergies:Allergies: NoneNone

Family History:Family History: NoneNone

Medications:Medications: Not known at this Not known at this

timetime

Social History:Social History: Non smokerNon smoker No alcohol useNo alcohol use No drug useNo drug use

Physical Exam in ER:Physical Exam in ER:

Vitals:Vitals: BP: 121/60BP: 121/60 Pulse: 65Pulse: 65 RR: 18RR: 18 Temp: 97Temp: 97

General:General: alert and orientedalert and oriented

Skin:Skin: Clear/noClear/no rashesrashes

HEENT:HEENT: No abn. findingsNo abn. findings

Thyroid:Thyroid: Not enlarged on Not enlarged on

palpationpalpation

Lungs:Lungs: Clear & NADClear & NAD

Cardiac:Cardiac: SS11SS22 & NAD & NAD

Physical Exam Continued:Physical Exam Continued:

Abdomen:Abdomen: Soft on palpationSoft on palpation No massesNo masses No organomegalyNo organomegaly + BS on ascultation+ BS on ascultation

Rectal:Rectal: Melena Melena HematacheziaHematachezia

Extremities:Extremities: No edema/calf No edema/calf

painpain

Laboratory Results in ER:Laboratory Results in ER:

H&H: 6.7/19.1H&H: 6.7/19.1 PT: 11.8PT: 11.8 INR: 0.99INR: 0.99 PTT: 22.8PTT: 22.8 Lipase: 121Lipase: 121 Amylase: 81Amylase: 81 Sodium: 139Sodium: 139 Potassium: 4.2Potassium: 4.2

Chloride: 105Chloride: 105 Bicarbonate: 22Bicarbonate: 22 BUN: 33BUN: 33 Creatinine: 1.1Creatinine: 1.1 Glucose: 170Glucose: 170

Assessment & Plan:Assessment & Plan: R/O diverticulosisR/O diverticulosis R/O polypsR/O polyps NPONPO Monitor vitalsMonitor vitals IVF D5% NS 50 cc/hrIVF D5% NS 50 cc/hr PRBCPRBC Tagamet 300mg IV q 8 hrs.Tagamet 300mg IV q 8 hrs. Monitor labs. (H&H)Monitor labs. (H&H) Consult GI: sigmoidoscopy/colonoscopyConsult GI: sigmoidoscopy/colonoscopy

Lower Endoscopy Report:Lower Endoscopy Report:

Indication for procedure:Indication for procedure: Hematochezia Hematochezia Level of insertion: Level of insertion: up to cecum; colon up to cecum; colon

180cm.180cm. Findings:Findings: diverticulosis from the proximal diverticulosis from the proximal

descending to proximal transverse colon. descending to proximal transverse colon. Full diverticulosis in ascending colon with Full diverticulosis in ascending colon with blood clots. But no active bleeding. Internal blood clots. But no active bleeding. Internal hemorrhoids found as well as colonic polyps hemorrhoids found as well as colonic polyps in distal ascending colon.in distal ascending colon.

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Impression & Dx:Impression & Dx: Diverticulosis from Diverticulosis from the splenic flexure to proximal the splenic flexure to proximal transverse with blood clots but no active transverse with blood clots but no active bleeding. Internal hemorrhoids found as bleeding. Internal hemorrhoids found as well.well.

Recommendation:Recommendation:

1. Surgery for subtotal colectomy.1. Surgery for subtotal colectomy.

2. Monitor CBC2. Monitor CBC

3. Post Op - high fiber/lactose free diet.3. Post Op - high fiber/lactose free diet.

Surgical Procedure Surgical Procedure Used:Used:

Surgical Procedure Used:Surgical Procedure Used:

The procedure is done under general anesthesia.The procedure is done under general anesthesia. An incision is made in the abdomen. The incision is An incision is made in the abdomen. The incision is

carried through the wall of the abdomen to expose carried through the wall of the abdomen to expose the bowel.the bowel.

The diseased portion of the colon is identified and The diseased portion of the colon is identified and that portion of the colon and it’s blood supply is that portion of the colon and it’s blood supply is divided and removed.divided and removed.

A stapler placed across the colon seals the colon on A stapler placed across the colon seals the colon on each side of the stapler and then cuts the colon each side of the stapler and then cuts the colon between the stables. Then the small bowel is joined between the stables. Then the small bowel is joined (anastamosis) to the rectum using a specific (anastamosis) to the rectum using a specific instrument. After the surgery the abdominal instrument. After the surgery the abdominal wound was closed with staples.wound was closed with staples.

Surgical Procedure Used:Surgical Procedure Used:(However anastamosis was of the (However anastamosis was of the ileum not the colon to the rectum)ileum not the colon to the rectum)

Postoperative Status:Postoperative Status: Postop this patient did very well. She had no physical Postop this patient did very well. She had no physical

complaints of abdominal pain of tenderness on exam. complaints of abdominal pain of tenderness on exam. She had + BS and she was having loose stools which She had + BS and she was having loose stools which was expected. Her vitals remained stable and she was was expected. Her vitals remained stable and she was in good spirit. The rest of her physical exam was in good spirit. The rest of her physical exam was normal. The incision had no signs of erythema, edema, normal. The incision had no signs of erythema, edema, infection or discharge and we removed the staples on infection or discharge and we removed the staples on post op day #8. She was put on a low residue/lactose post op day #8. She was put on a low residue/lactose free diet. PT was call to start the patient ambulating free diet. PT was call to start the patient ambulating and depending on her H&H and whether or not blood and depending on her H&H and whether or not blood was found in her stool, she would be dischargedwas found in her stool, she would be discharged

Diverticulosis:Diverticulosis:

It is a condition that is common in Western society.It is a condition that is common in Western society. It increases with age & it is present in approx. 75% It increases with age & it is present in approx. 75%

of Americans over age 80.of Americans over age 80. It is associated with diverticula, which are It is associated with diverticula, which are

protrusions of the innermost lining of the colon protrusions of the innermost lining of the colon through the muscular outer layer of the colon wall.through the muscular outer layer of the colon wall.

The diverticula can become inflamed, a condition The diverticula can become inflamed, a condition called called diverticulitisdiverticulitis which can cause perforation of a which can cause perforation of a bowel abscess, bleeding, obstruction of the bowel or bowel abscess, bleeding, obstruction of the bowel or fistulae of the colon.fistulae of the colon.

Pathophysiology:Pathophysiology:

A decrease in fiber in the diet is A decrease in fiber in the diet is associated with a high incidence of associated with a high incidence of diverticulosis in Western diverticulosis in Western population.population.

Symptoms and Symptoms and Complications of Complications of Diverticulosis:Diverticulosis:

Bleeding (usually right sided)may be Bleeding (usually right sided)may be massivemassive

Diverticulitis(LLQ pain which is Diverticulitis(LLQ pain which is cramping or steady, change in bowel cramping or steady, change in bowel habits, fever, chills, anorexia, nausea, habits, fever, chills, anorexia, nausea, vomiting and dysuria)vomiting and dysuria)

Asymptomatic (80%) usually diagnosed Asymptomatic (80%) usually diagnosed incidentally on endoscopy or BE.incidentally on endoscopy or BE.

Diagnosis of Diagnosis of Diverticulosis:Diverticulosis:

Usually incidentally during a barium x-Usually incidentally during a barium x-ray.ray.

Evaluation of older patients with recent Evaluation of older patients with recent onset of bowel disturbances should onset of bowel disturbances should include:include:– Occult bloodOccult blood– CBCCBC– SigmoidoscopySigmoidoscopy– Barium enema or colonoscopyBarium enema or colonoscopy

Colonoscopy

Differential Diagnosis of Differential Diagnosis of Lower GI Hemorrhage:Lower GI Hemorrhage:

Colonic diverticular Dz.Colonic diverticular Dz. Colonic vascular ectasiasColonic vascular ectasias Small intestinal diverticular DzSmall intestinal diverticular Dz. (Meckels diverticulum, . (Meckels diverticulum,

pseudodiverticula).pseudodiverticula). Inflammatory bowel Dz. Inflammatory bowel Dz. (Chronic Ulcerative Colitis, Crohn’s (Chronic Ulcerative Colitis, Crohn’s

Dz.).Dz.). Colonic NeplasmsColonic Neplasms Small intestinal neoplasmsSmall intestinal neoplasms AngiodysplasiaAngiodysplasia Aorticenteric fistulaeAorticenteric fistulae Colitis Colitis (infection, ischemia, radiation induced).(infection, ischemia, radiation induced). Internal Hemorrhoidal Dz.Internal Hemorrhoidal Dz.

Treatments of Diverticulosis:Treatments of Diverticulosis:

Treatment depends on the severity and location Treatment depends on the severity and location of the diverticulosis, as well as the status of the of the diverticulosis, as well as the status of the patient.patient.

A high fiber diet is recommended A high fiber diet is recommended Broad spectrum antibiotics if asymptomaticBroad spectrum antibiotics if asymptomatic Examples of surgical procedures used are:Examples of surgical procedures used are:

– colostomy colostomy – iliostomyiliostomy– right or left hemicolectomyright or left hemicolectomy– subtotal colectomy with anastamosissubtotal colectomy with anastamosis

Continued:Continued: The indications to operate on a patient with The indications to operate on a patient with

diverticulosis are:diverticulosis are:– complications of diverticulitis (abscess, complications of diverticulitis (abscess,

fistula, obstruction, stricture).fistula, obstruction, stricture).– Recurrent episodes of diverticulitisRecurrent episodes of diverticulitis– HemorrhageHemorrhage– Suspected carcinomaSuspected carcinoma– Prolonged symptomsProlonged symptoms– ischemic colonischemic colon– toxic megacolontoxic megacolon

Complications of Colon Complications of Colon Surgery:Surgery:

Postoperative bleedingPostoperative bleeding Dehiscence or breakdown of the Dehiscence or breakdown of the

anastomosisanastomosis Recurrence of a tumorRecurrence of a tumor Wound infectionWound infection Urinary or respiratory infectionUrinary or respiratory infection DVT with or without PEDVT with or without PE Urinary retentionUrinary retention Adhesions with bowel obstructionAdhesions with bowel obstruction Obstruction at the anastomosis siteObstruction at the anastomosis site

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