Disorders of Small & Large Disorders of Small & Large BowelBowel

(Specially dedicated to Mark Wahba -- hope this helps buddy)(Specially dedicated to Mark Wahba -- hope this helps buddy)

Moritz HaagerMoritz Haager

April 01, 2004April 01, 2004

OutlineOutline

AppendicitisAppendicitisUseful & useless testsUseful & useless tests

Mesenteric IschemiaMesenteric IschemiaWhen to suspect it & how to chase itWhen to suspect it & how to chase it

Diverticular diseaseDiverticular diseaseWho has it? Whom to Tx & how.Who has it? Whom to Tx & how.

Case 1Case 1

25 yo female c/o right lower quadrant pain.25 yo female c/o right lower quadrant pain.What is your differential diagnosis?What is your differential diagnosis?How does you DDx change if she is 5 yo? 85 How does you DDx change if she is 5 yo? 85

yo? Male?yo? Male?Which historical & physical exam features are Which historical & physical exam features are

helpful in narrowing it down?helpful in narrowing it down?What lab & DI tests are useful?What lab & DI tests are useful?Who can go home, who should stay, who needs Who can go home, who should stay, who needs

to go to the OR?to go to the OR?

Appendicitis Fast FactsAppendicitis Fast Facts

Incidence 1/1000Incidence 1/1000Lifetime risk 6% -- genetic predispositionLifetime risk 6% -- genetic predispositionMortality 0.1% (20-60x higher in perf’d)Mortality 0.1% (20-60x higher in perf’d)Initially misdiagnosed in 30%Initially misdiagnosed in 30%Accepted negative laparotomy rate 20-25%Accepted negative laparotomy rate 20-25%Perforation rate 20%Perforation rate 20%

70% in <9 yo or > 60 yo70% in <9 yo or > 60 yo

True or False?True or False?

Appendicitis can occur at any ageAppendicitis can occur at any age T: most common in 10-30 yoT: most common in 10-30 yo

Appendicitis can present w/ LUQ painAppendicitis can present w/ LUQ pain T: rare but possible (0.06%)T: rare but possible (0.06%)

Appendicitis does not recurAppendicitis does not recur F: estimated to recur in 6%F: estimated to recur in 6%

Definite gastroenteritis rules out appendicitisDefinite gastroenteritis rules out appendicitis F: viral & other infections can actually cause F: viral & other infections can actually cause

appendicitis due to lymphoid hypertrophyappendicitis due to lymphoid hypertrophy

Appendicitis DDxAppendicitis DDx

GastroenteritisGastroenteritis Crohn’sCrohn’s Testicular torsionTesticular torsion Meckel’s diverticulumMeckel’s diverticulum DiverticulitisDiverticulitis Mesenteric adenitisMesenteric adenitis CholelithiasisCholelithiasis Pancreatitis Pancreatitis Bowel obstruction Bowel obstruction

Pelvic inflammatory Pelvic inflammatory diseasedisease

EndometriosisEndometriosis Ovarian cystOvarian cyst Tubo-ovarian abscessTubo-ovarian abscess Ectopic pregnancyEctopic pregnancy MittelschmerzMittelschmerz PyelonephritisPyelonephritis Urinary Tract Urinary Tract

infectioninfection

History & PhysicalHistory & Physical

Aim to differentiate pts into 3 groupsAim to differentiate pts into 3 groups1.1. High suspicion for appendicitis – need for High suspicion for appendicitis – need for

immediate surgeryimmediate surgery i.e. classic presentationi.e. classic presentation

2.2. Intermediate suspicion for appendicitis – Intermediate suspicion for appendicitis – no clear-cut need to go to OR yetno clear-cut need to go to OR yet Atypical presentationAtypical presentation

3.3. Low suspicion for appendicitisLow suspicion for appendicitis

Diagnostic StrategiesDiagnostic Strategies

Hx & P/EHx & P/ELabs: CBC & diff, CRP, Labs: CBC & diff, CRP, ββ-HCG-HCG, U/A, etc, U/A, etcRadiographyRadiography

Plain filmsPlain filmsUltrasoundUltrasoundCTCT

Observation & serial examinationObservation & serial examinationLaparoscopyLaparoscopy

The onlyabsolutely labnecessary test

Classical PresentationClassical Presentation

Good story: Pain starts as vague peri-umbillical Good story: Pain starts as vague peri-umbillical discomfort discomfort localizes to RLQ as sharp pin-point localizes to RLQ as sharp pin-point painpain

WBC > 10 WBC > 10 Rebound & guarding at McBurney’s PointRebound & guarding at McBurney’s Point Associated N & V, anorexiaAssociated N & V, anorexia FeverFever Present within 48 hrs of onsetPresent within 48 hrs of onset

Occurs in only 50-60% of patientsOccurs in only 50-60% of patients

If you didn’t know & were to If you didn’t know & were to embarrassed to askembarrassed to askPsoas signPsoas sign

With pt supine, get pt to flex hip against With pt supine, get pt to flex hip against resistance by pushing down against knee -- pain resistance by pushing down against knee -- pain = +ve= +ve

Obturator signObturator signPassively flex hip & knee and internally rotate Passively flex hip & knee and internally rotate

leg at the hip -- pain = +veleg at the hip -- pain = +ve

Rosvings signRosvings signpress down in LLQ then release suddenly -- press down in LLQ then release suddenly --

pain = + vepain = + ve

Signs & SymptomsSigns & Symptoms

SymptomsSymptoms Abd pain Abd pain 97-97-

100%100% AnorexiaAnorexia 70-92%70-92% NauseaNausea 67-78%67-78% VomitingVomiting 49-74%49-74% RLQ migration RLQ migration 49-61%49-61% FeverFever 10-20%10-20% DiarrheaDiarrhea 4-16%4-16% ConstipationConstipation 4-16%4-16%

RLQ pain LR+ 8.0; LR- 0.2RLQ pain LR+ 8.0; LR- 0.2 Rigidity LR+ 4.0; LR-0.82Rigidity LR+ 4.0; LR-0.82 Migration LR+ 3.1; LR- 0.5Migration LR+ 3.1; LR- 0.5 Previous similar pain LR- 0.3Previous similar pain LR- 0.3

SignsSigns Abd tendernessAbd tenderness 95-100%95-100% RLQ tenderness RLQ tenderness 90-95%90-95% ReboundRebound 33-68%33-68% Rectal tenderness Rectal tenderness 30-40%30-40% Cervical motion Cervical motion

tenderness tenderness 30%30% Rigidity Rigidity 12%12% Psoas signPsoas sign 3-5%3-5% Obturator sign Obturator sign 5-8%5-8% Rosvings sign Rosvings sign 5%5% Palpable mass Palpable mass <5%<5% Avg Temp Avg Temp 37.937.9ooCC

Wagner et al. Does this patient have appendicitis?JAMA 1996; 276: 1589-94

Accuracy of clinical findingsAccuracy of clinical findingsFindingFinding Sensitivity (%)Sensitivity (%) Specificity (%)Specificity (%)

Pain Pain beforebefore N&V* N&V* 100100 6464

AnorexiaAnorexia 8484 6666

RLQ painRLQ pain 8181 5353

Rosving’sRosving’s 6868 5858

FeverFever 6767 6969

ReboundRebound 6363 6969

NauseaNausea 58-6858-68 37-4037-40

VomitingVomiting 49-5149-51 45-6945-69

GuardingGuarding 39-7439-74 57-8457-84

Psoas signPsoas sign 1616 9595* based on only one studyWagner et al. Does this patient have appendicitis?

JAMA 1996; 276: 1589-94

Do you need to do a Rectal?Do you need to do a Rectal?

NONOSens 41%, Spec 77%Sens 41%, Spec 77%LR+ 0.83 - 5.34LR+ 0.83 - 5.34LR- 0.36 - 1.15LR- 0.36 - 1.15

Wagner et al. Does this patient have appendicitis? JAMA 1996; 276: 1589-Wagner et al. Does this patient have appendicitis? JAMA 1996; 276: 1589-9494

““Pain on rectal palpation has no Pain on rectal palpation has no discriminatory or predictive power”discriminatory or predictive power”

Andersson. Meta-analysis of the clinical and laboratory diagnosis of Andersson. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Brit J Surg. 2004; 91: 28-37appendicitis. Brit J Surg. 2004; 91: 28-37

Utility of the WBC countUtility of the WBC count

Elevated in 70-90% of pts w/ appendicitisElevated in 70-90% of pts w/ appendicitisSomewhat helpful if >19 or <7 but this Somewhat helpful if >19 or <7 but this

happens in only ~20% of ptshappens in only ~20% of ptsSnyder & Hayden. Accuracy of leukocyte count in Snyder & Hayden. Accuracy of leukocyte count in

diagnosis of acute appendicitis. Ann Emerg Med. diagnosis of acute appendicitis. Ann Emerg Med. 1999; 33: 565-5741999; 33: 565-574

VeryVery non-specific – many of the other non-specific – many of the other disorders on the DDx will have elevated disorders on the DDx will have elevated white countwhite count

Andersson. Meta-analysis of the clinical and laboratory Andersson. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Brit J Surg. 2004; 91: 28-37diagnosis of appendicitis. Brit J Surg. 2004; 91: 28-37

No clinical or laboratory parameter alone found to No clinical or laboratory parameter alone found to have sufficient discriminatory or predictive have sufficient discriminatory or predictive capacitycapacity

Performance increased considerably when 2 or Performance increased considerably when 2 or more variables were combinedmore variables were combined

Most useful variables were clinical markers of Most useful variables were clinical markers of peritonitis, pain migration, and WBC & diff peritonitis, pain migration, and WBC & diff combined w/ CRPcombined w/ CRP

Caveat: highly selected population of pts w/ Caveat: highly selected population of pts w/ suspected appendicitis admitted for further suspected appendicitis admitted for further evaluationevaluation

RadiographyRadiography

Plain filmsPlain films0% sensitivity for appendicitis– a waste of time 0% sensitivity for appendicitis– a waste of time

if appy is your 1if appy is your 1stst thought thoughtUltrasoundUltrasound

Sensitivity 75-90%, Specificity 86-100%Sensitivity 75-90%, Specificity 86-100%Able to identify alternate diagnoses esp. in Able to identify alternate diagnoses esp. in

female ptsfemale ptsCTCT

Sensitivity 90-100%, specificity 91-99%Sensitivity 90-100%, specificity 91-99%Able to identify alternate diagnosesAble to identify alternate diagnoses

Ultrasound (Graded Compression)Ultrasound (Graded Compression)

Test CharacteristicsTest Characteristics Sensitivity 75-90%, Specificity 86-100%Sensitivity 75-90%, Specificity 86-100%

ProsPros No radiation, safe in kids, pregnant ptsNo radiation, safe in kids, pregnant pts Can identify alternate Dx esp. in female ptsCan identify alternate Dx esp. in female pts

ConsCons Difficult for us to get locallyDifficult for us to get locally Operator-dependantOperator-dependant Limited in obese pts or ++ bowel gasLimited in obese pts or ++ bowel gas Identifies alternate Dx less often than CTIdentifies alternate Dx less often than CT Painful Painful

CTCT Test characteristicsTest characteristics

Sensitivity 90-100%, specificity 91-99%Sensitivity 90-100%, specificity 91-99% ProsPros

Identifies alternate Dx more often than U/SIdentifies alternate Dx more often than U/S Fast & accessible in our practice settingFast & accessible in our practice setting

ConsCons Radiation dose (~100 CXR’s)Radiation dose (~100 CXR’s) Multiple techniques in literature: controversial as to which is Multiple techniques in literature: controversial as to which is

best but all ~90-100% sensitivebest but all ~90-100% sensitiveSpiral vs. conventionalSpiral vs. conventionalFocused vs. entire abdomenFocused vs. entire abdomenUnenhanced, various combinations of IV, oral, rectal contrastUnenhanced, various combinations of IV, oral, rectal contrastLess accurate in pts w/ little intraabdominal fatLess accurate in pts w/ little intraabdominal fat

Which test is better?Which test is better?

2 prospective RCT’s of U/S vs. CT2 prospective RCT’s of U/S vs. CTCT more sensitive & specific than U/SCT more sensitive & specific than U/S

94-97% sensitive vs. 76 – 100% for U/S94-97% sensitive vs. 76 – 100% for U/S100% specificity vs. 76-90% for U/S100% specificity vs. 76-90% for U/S

More alternate Dx identified by CTMore alternate Dx identified by CTHorton et al. Am J Surg 2000; 179: 379-81Horton et al. Am J Surg 2000; 179: 379-81Walker et al. Am J Surg 2000; 180: 450-55Walker et al. Am J Surg 2000; 180: 450-55

Which test is better?Which test is better?

120 consecutive pts 8-81 yo w/ ?appy who were to 120 consecutive pts 8-81 yo w/ ?appy who were to well to go to OR but too ill to simply D/Cwell to go to OR but too ill to simply D/C

Did focused CT w/ rectal contrast & U/S within 1 Did focused CT w/ rectal contrast & U/S within 1 hr on all ptshr on all pts

Gold standard was pathology or clinical f/u x 6 moGold standard was pathology or clinical f/u x 6 mo CT: 95% sensitive, 89% specificCT: 95% sensitive, 89% specific U/S: 87% sensitive, 74% specificU/S: 87% sensitive, 74% specific CT identified 14 alternate Dx vs. 9 for U/SCT identified 14 alternate Dx vs. 9 for U/S U/S missed 2/3 of pts w/ perforationU/S missed 2/3 of pts w/ perforation

Pickuth et al. Suspected acute appendicitis: Is Pickuth et al. Suspected acute appendicitis: Is ultrasonography or computed tomography the preferred ultrasonography or computed tomography the preferred imaging technique? Eur J Surg. 2000; 166: 315-19imaging technique? Eur J Surg. 2000; 166: 315-19

Does imaging change mgmt?Does imaging change mgmt?

2 studies of CT in pts w/ suspected 2 studies of CT in pts w/ suspected appendicitis comparing Tx plan before & appendicitis comparing Tx plan before & after access to results of scansafter access to results of scansCT changed disposition in 27 – 59% of ptsCT changed disposition in 27 – 59% of ptsPrevented d/c of ~3% pts w/ appendicitisPrevented d/c of ~3% pts w/ appendicitisPrevented negative laparotomy in 3-13%Prevented negative laparotomy in 3-13%Alternate Dx in 11-20%Alternate Dx in 11-20%

Frank et al. Unenhanced helical CT scanning of the abdomen and Frank et al. Unenhanced helical CT scanning of the abdomen and pelvis changes disposition of patients presenting to the emergency pelvis changes disposition of patients presenting to the emergency department with possible acute appendicitis. J Emerg Med 2002; department with possible acute appendicitis. J Emerg Med 2002; 23: 1-723: 1-7

Rao et al. Effect of computed tomography of the appendix on Rao et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Eng J Med. treatment of patients and use of hospital resources. N Eng J Med. 1998; 338: 141-61998; 338: 141-6

Bottom-lineBottom-line

Pts w/ high pre-test probability should go Pts w/ high pre-test probability should go for appendectomy regardless of imaging for appendectomy regardless of imaging resultresult

Pts w/ very low pre-test probability should Pts w/ very low pre-test probability should be clearly instructed when to return for re-be clearly instructed when to return for re-evaluationevaluation

Pts who fall in b/w these extremes benefit Pts who fall in b/w these extremes benefit most from imagingmost from imaging

Bottom-lineBottom-line

Both are good but if I had only one test I’d take Both are good but if I had only one test I’d take the CTthe CT

If I had only 5 CT’s or U/S’s available per month If I had only 5 CT’s or U/S’s available per month I’d use them on women rather than menI’d use them on women rather than men

If I had a very skinny pt, pregnant pt, or kid I’d If I had a very skinny pt, pregnant pt, or kid I’d prefer to do a U/Sprefer to do a U/S

If I thought the main DDx was gastro vs. appy I’d If I thought the main DDx was gastro vs. appy I’d be happy w/ a focused CT ….be happy w/ a focused CT ….

……but if I had the sense this pt has something but if I had the sense this pt has something going on which could be appy but I’m really not going on which could be appy but I’m really not sure I’d want the entire belly CT preferably with sure I’d want the entire belly CT preferably with contrastcontrast

Observation & Serial examsObservation & Serial exams

Reasonable alternative but not well studiedReasonable alternative but not well studiedProPro

Observation for 6-10 hrs in intermediate-risk pts Observation for 6-10 hrs in intermediate-risk pts does not appear to increase risk of perforation while does not appear to increase risk of perforation while potentially lowering negative appy ratepotentially lowering negative appy rate

ConConIn kids perforation is the rule – delays may increase In kids perforation is the rule – delays may increase

complicationscomplicationsCost of admission may outweigh cost of DICost of admission may outweigh cost of DIIf observed in the department can slow flowIf observed in the department can slow flow

Proposed Appy AlgorithmProposed Appy Algorithm

Paulson et al. Suspected appendicitis. N Eng J Med 2003; 348: 236-42

Case 2Case 2

61 yo female with severe acute abdominal 61 yo female with severe acute abdominal pain for 3 hrs. Has vomited and had 3 pain for 3 hrs. Has vomited and had 3 watery stools. watery stools.

Afebrile, no evidence of peritonitisAfebrile, no evidence of peritonitisPMHx remarkable for rheumatic fever & PMHx remarkable for rheumatic fever &

HTN.HTN.

Mesenteric IschemiaMesenteric Ischemia

Simply stated this is blocked or restricted blood Simply stated this is blocked or restricted blood flow to the gutflow to the gut Pathophysiology essentially same as that for CAD & Pathophysiology essentially same as that for CAD &

thromboembolic cardiovascular dzthromboembolic cardiovascular dz 4 major types w/ different Tx & prognosis4 major types w/ different Tx & prognosis

Occlusive (80%)Occlusive (80%)ArterialArterial

Embolic (50%)Embolic (50%) Thrombotic (15%)Thrombotic (15%)

Venous Venous Thrombotic (15%)Thrombotic (15%)

Non-occlusive (20%)Non-occlusive (20%)Low flow states e.g. sepsis, hypovolemia Low flow states e.g. sepsis, hypovolemia “shock bowel” “shock bowel”

AnatomyAnatomy

Celiac TrunkCeliac Trunk Pharynx, esophagus, stomach, proximal duodenum, Pharynx, esophagus, stomach, proximal duodenum,

liver, GB, pancreas, spleenliver, GB, pancreas, spleen SMASMA

Distal duodenum, jejunum, ileum, cecum, ascending Distal duodenum, jejunum, ileum, cecum, ascending colon, 2/3 transverse coloncolon, 2/3 transverse colon

IMAIMA Distal 1/3 transverse colon, descending & sigmoid Distal 1/3 transverse colon, descending & sigmoid

colon, rectumcolon, rectum

Extensive collateral supply & overlap exist b/w Extensive collateral supply & overlap exist b/w these = protective to a large degreethese = protective to a large degree

Venous system parallels arterial systemVenous system parallels arterial system

Clinical PresentationClinical Presentation

Triad of acute abdo pain, diarrhea, & vomiting in Triad of acute abdo pain, diarrhea, & vomiting in high risk pthigh risk pt

Very non-specific especially early when its critical to Very non-specific especially early when its critical to make the Dx – broad DDxmake the Dx – broad DDx ‘‘Time is gut” & dead gut frequently = dead ptTime is gut” & dead gut frequently = dead pt

Peritoneal signs = transmural necrosisPeritoneal signs = transmural necrosis 70-90% mortality untreated70-90% mortality untreated 45-50% mortality treated w/ peritonitis45-50% mortality treated w/ peritonitis ~10% mortality if early Dx (no peritonitis)~10% mortality if early Dx (no peritonitis)

Most useful S & S:Most useful S & S: Visceral pain out of proportion to examVisceral pain out of proportion to exam

Dull, not worse w/ movement or palpation Dull, not worse w/ movement or palpation Older & Risk factors for atherosclerotic +/- embolic dz Older & Risk factors for atherosclerotic +/- embolic dz

Mesenteric arterial embolic DzMesenteric arterial embolic Dz

Vast majority involve SMA (45Vast majority involve SMA (45oo angle) angle) Better prognosis than thrombosisBetter prognosis than thrombosis

Emboli lodge at distal branch points rather than origin Emboli lodge at distal branch points rather than origin smaller area of gut involvedsmaller area of gut involved

Tend to present earlier w/ more typical SxTend to present earlier w/ more typical Sx Better response to TxBetter response to Tx

Risk FactorsRisk Factors Older, CAD, Post-MI (mural thrombi), CHF, a fib, Older, CAD, Post-MI (mural thrombi), CHF, a fib,

valvular Dz, aortic dissection / aneurysm, aortic surgery, valvular Dz, aortic dissection / aneurysm, aortic surgery, angiography, Hx of thromboembolic Dzangiography, Hx of thromboembolic Dz

Mesenteric arterial thrombosisMesenteric arterial thrombosis

Occurs in more proximal vessel origin Occurs in more proximal vessel origin worse prognosisworse prognosis

SMA again most common siteSMA again most common siteAnalogous to CAD: angina & MIAnalogous to CAD: angina & MI

May have Hx of abdominal anginaMay have Hx of abdominal anginaStrong association w/ CADStrong association w/ CAD

Mesenteric venous thrombosisMesenteric venous thrombosis

Younger pts (can occur any age)Younger pts (can occur any age) Less mortality (20 – 50%)Less mortality (20 – 50%) 95% of all cases involve SMV95% of all cases involve SMV Risk factorsRisk factors

Hypercoagulable stateHypercoagulable statePolycythemia vera, myeloproliferative Dz, ATIII deficiency, Polycythemia vera, myeloproliferative Dz, ATIII deficiency,

protein C & S deficiency, DVT, malignancy, estrogen Tx, protein C & S deficiency, DVT, malignancy, estrogen Tx, pregnancy, sickle cellpregnancy, sickle cell

Intraabdominal inflammationIntraabdominal inflammationPancreatitis, diverticulitis, appendicitis, cholangitisPancreatitis, diverticulitis, appendicitis, cholangitis

TraumaTrauma OtherOther

CHF, renal failure, the bends, portal HTNCHF, renal failure, the bends, portal HTN

Non-occlusive mesenteric ischemiaNon-occlusive mesenteric ischemia

Due to mesenteric vasoconstriction or low-Due to mesenteric vasoconstriction or low-flow state secondary to other critical illnessflow state secondary to other critical illness

CVSCVSCHF, MI, Post CABG, CHF, MI, Post CABG,

Shock statesShock statesSeptic, hypovolemic, cardiogenic etcSeptic, hypovolemic, cardiogenic etc

DrugsDrugsInotropes, cocaine, ergots, digoxinInotropes, cocaine, ergots, digoxin

Diagnostic StrategiesDiagnostic Strategies

History & physicalHistory & physicalLabsLabs

WBC, lactate, CKWBC, lactate, CK

Diagnostic ImagingDiagnostic ImagingPlain filmsPlain filmsCTCTU/SU/SAngiographyAngiography

Utility of lab testsUtility of lab tests WBCWBC

Elevated in most but decreased sensitivity early, & very Elevated in most but decreased sensitivity early, & very non-specificnon-specific

CKCK 54% sens at 2 hrs, 75% sens at 4 hrs, 83% spec54% sens at 2 hrs, 75% sens at 4 hrs, 83% spec

LactateLactate Up to 96- 100% sensitive, 42% specific (at what time Up to 96- 100% sensitive, 42% specific (at what time

point)point) ? ? αα-Glutathione S-transferase -Glutathione S-transferase

Promising but limited studies at the momentPromising but limited studies at the moment Paucity of good studies on markers Paucity of good studies on markers Generally too insensitive & non-specific Generally too insensitive & non-specific

Plain filmsPlain films

Only 28-30% sensitiveOnly 28-30% sensitiveMany non-specific findings..Many non-specific findings..

Ileus, free air, obstructionIleus, free air, obstruction

……or specific findings (too) late or specific findings (too) late Pneumatosis intestinalis, portal venous gas, Pneumatosis intestinalis, portal venous gas,

thickened bowel wall, thumbprintingthickened bowel wall, thumbprinting

Too insensitive & nonspecific to aid in Too insensitive & nonspecific to aid in early Dxearly Dx

CTCT

Sens 64-82%Sens 64-82%Look for evidence of ischemia in bowel wall & Look for evidence of ischemia in bowel wall &

mesentarymesentaryEvidence of clot in SMAEvidence of clot in SMA

First investigation done routinely hereFirst investigation done routinely hereIf suspecting mesenteric ischemia very If suspecting mesenteric ischemia very

important to let your radiologist knowimportant to let your radiologist knowGood but not good enoughGood but not good enough

If CT is negative & high pre-test probability If CT is negative & high pre-test probability you need an angiogramyou need an angiogram

UltrasoundUltrasound

Doppler can determine major obstruction to flow Doppler can determine major obstruction to flow in both venous & arterial systemsin both venous & arterial systems See dilated, tubular vessels full of echogenic material See dilated, tubular vessels full of echogenic material

(clot) and abnormal flow(clot) and abnormal flow

Limitations Limitations Used & studied primarily in venous thrombosis & Used & studied primarily in venous thrombosis &

chronic mesenteric ischemiachronic mesenteric ischemia Really don’t know much about how it performs for Really don’t know much about how it performs for

acute mesenteric ischemiaacute mesenteric ischemia Only good for more proximal blockagesOnly good for more proximal blockages Has the usual limitations inherent to all U/S examsHas the usual limitations inherent to all U/S exams

AngiographyAngiography

Gold standard test (~90% sens)Gold standard test (~90% sens) Diagnostic & therapeuticDiagnostic & therapeutic

Infusions of vasodilators into SMA (papaverine)Infusions of vasodilators into SMA (papaverine) AngioplastyAngioplasty

Controversies:Controversies: When & on whom to do itWhen & on whom to do it

DrawbacksDrawbacks Time-consumingTime-consuming Risks of contrast & invasive procedureRisks of contrast & invasive procedure ExpensiveExpensive

Angiography: Early vs. late strategyAngiography: Early vs. late strategy

Most authors feel angiography should be done Most authors feel angiography should be done early in pts w/o peritonitis & high suspicionearly in pts w/o peritonitis & high suspicionCan buy time (papaverine)Can buy time (papaverine)Can aid in surgical decision makingCan aid in surgical decision making

Surgical: embolectomy, thrombectomy, endarterectomy, Surgical: embolectomy, thrombectomy, endarterectomy, bypass graftingbypass grafting

Non-surgical: angioplastyNon-surgical: angioplasty

Early (before peritonitis) angiography & Early (before peritonitis) angiography & intervention decreased mortality from 70-90% intervention decreased mortality from 70-90% to 10% in several studiesto 10% in several studies

Down side is high rate of negative angios & Down side is high rate of negative angios & associated risks & costsassociated risks & costs

Angiography: When not to do itAngiography: When not to do it

Contraindicated in:Contraindicated in:Unstable hypotensive pts on vasopressorsUnstable hypotensive pts on vasopressors

Difficult to differentiate b/w occlusive & non-Difficult to differentiate b/w occlusive & non-occlusive etiologiesocclusive etiologies

Can’t infuse vasodilatorsCan’t infuse vasodilators

Pts w/ peritonitisPts w/ peritonitisDelays surgeryDelays surgery

MRIMRI

Gadolinium-enhanced MRA appears to be Gadolinium-enhanced MRA appears to be very goodvery good

MRI best at differentiating potentially MRI best at differentiating potentially viable from dead gutviable from dead gut

Currently limited by length of acquisition Currently limited by length of acquisition time & cost but will likely play larger role time & cost but will likely play larger role in the futurein the future

ED managementED management

ABC’sABC’s Maintain COMaintain CO Maximize oxygenationMaximize oxygenation

IV AntibioticsIV Antibiotics Broad spectrum (amp, gent, flagyl)Broad spectrum (amp, gent, flagyl)

Glucagon?Glucagon? Increases splanchnic blood flowIncreases splanchnic blood flow Effective in animal models but no evidence in humansEffective in animal models but no evidence in humans

Get radiology & surgery involved earlyGet radiology & surgery involved early Restore flow (papaverine, angioplasty, thrombolytics, Restore flow (papaverine, angioplasty, thrombolytics,

surgery)surgery) Resect dead gut & anticoagulate post-op Resect dead gut & anticoagulate post-op

PapaverinePapaverine

VasodilatorVasodilatorPhosphodiesterase inhibitor – increases cAMP Phosphodiesterase inhibitor – increases cAMP

which causes smooth muscle relaxationwhich causes smooth muscle relaxationGiven as intraarterial infusion into SMAGiven as intraarterial infusion into SMA

No – minimal systemic effects as 90% 1No – minimal systemic effects as 90% 1stst pass pass metabolism in livermetabolism in liver

60 mg bolus, then 30-60 mg/h infusion60 mg bolus, then 30-60 mg/h infusion

Good for occlusive & non-occlusive etiologiesGood for occlusive & non-occlusive etiologiesImproves survival by 20-50%Improves survival by 20-50%

CaseCase

75 yo male c/o worsening LLQ pain x 2/775 yo male c/o worsening LLQ pain x 2/7Febrile 39.1Febrile 39.1oo, WBC 19,000, WBC 19,000Voluntary guarding LLQVoluntary guarding LLQ

Diverticular diseaseDiverticular disease

DiverticulosisDiverticulosisPseudodiverticula Pseudodiverticula

Outpouchings of mucosa & submucosa through Outpouchings of mucosa & submucosa through muscular wall at weakest points (vasa recta)muscular wall at weakest points (vasa recta)

Sigmoid > than R colonSigmoid > than R colonWestern populations >> developing countriesWestern populations >> developing countriesUnclear pathophysiology but related to low fiber Unclear pathophysiology but related to low fiber

diet & advanced agediet & advanced age50-60 yo – 30% have it50-60 yo – 30% have it70 yo – 50%70 yo – 50%85 yo – 66%85 yo – 66%

Diverticular diseaseDiverticular disease

DiverticulosisDiverticulosis85% will remain asymptomatic85% will remain asymptomatic15% will develop symptoms15% will develop symptoms

~11% develop painful diverticulosis ~11% develop painful diverticulosis IBS-like Sx: abdo pain, bloating, diarrhea and/or IBS-like Sx: abdo pain, bloating, diarrhea and/or

constipationconstipationPrecise mechanism of pain remains unclear ? low-grade Precise mechanism of pain remains unclear ? low-grade

inflammation inflammation neuro-muscular dysfunction & spasm neuro-muscular dysfunction & spasm

~4% go on to develop diverticulitis~4% go on to develop diverticulitis1-2 % require admission & ~0.5% will require 1-2 % require admission & ~0.5% will require

surgerysurgery

DiverticulitisDiverticulitis

Inflammation & infection of diverticulaInflammation & infection of diverticulaTriad of LLQ pain, fever, leukocytosisTriad of LLQ pain, fever, leukocytosisPathogenesis unclear -- ?obstruction of Pathogenesis unclear -- ?obstruction of

diverticula (mechanism similar to appendicitis)diverticula (mechanism similar to appendicitis)

3 types3 typesAsymptomaticAsymptomaticAcute diverticulitisAcute diverticulitisComplicated diverticulitisComplicated diverticulitis

Obstruction, bleeding, perforationObstruction, bleeding, perforation

Diagnostic StrategiesDiagnostic Strategies

Hx & physicalHx & physicalLabsLabs

WBCWBC

RadiologyRadiologyPlain filmsPlain filmsCTCTWater-soluble contrast enemaWater-soluble contrast enemaBarium enemaBarium enemaEndoscopyEndoscopy

Plain filmsPlain films

Not sensitive or specific for diverticular Not sensitive or specific for diverticular diseasedisease

Primary utility in ruling out obstruction or Primary utility in ruling out obstruction or perforationperforation

Barium enemaBarium enema

Very good at identifying diverticular Very good at identifying diverticular disease BUT…disease BUT…

ABSOLUTELY contraindicated in ABSOLUTELY contraindicated in suspected diverticulitissuspected diverticulitisRisk of peritoneal extravasation if perforatedRisk of peritoneal extravasation if perforated

EndoscopyEndoscopy

Also very effective at identifying Also very effective at identifying diverticular dz BUTdiverticular dz BUT

NOT in diverticulitis b/c of risk of NOT in diverticulitis b/c of risk of perforationperforation

Water soluble contrast enemaWater soluble contrast enema

Safe in diverticulitisSafe in diverticulitis94% sensitive for diverticular dz94% sensitive for diverticular dzMay visualize May visualize

Perforation – contrast extravasationPerforation – contrast extravasationIntra- or peri-colonic massesIntra- or peri-colonic massesSinus tracts & fistulasSinus tracts & fistulas

CTCT

Test of choiceTest of choice 90-95% sens & 72% spec for diverticular dz90-95% sens & 72% spec for diverticular dz Able to establish extent of diseaseAble to establish extent of disease

Hinchey classificationHinchey classificationStage I: pericolic abscessStage I: pericolic abscessStage IIa: distant abscess amenable to percutaneous drainageStage IIa: distant abscess amenable to percutaneous drainageStage IIb: complex abscess +/- fistulaStage IIb: complex abscess +/- fistulaStage III: generalized purulent peritonitisStage III: generalized purulent peritonitisStage IV: fecal peritonitisStage IV: fecal peritonitis

Can determine alternate intraabdominal pathologyCan determine alternate intraabdominal pathology

ED management: DiverticulosisED management: Diverticulosis

AnalgesiaAnalgesiaHeatHeatAnticholinergicsAnticholinergicsAntispasmodicsAntispasmodics

Prevent disease progressionPrevent disease progressionStool softenersStool softenersHigh fiber dietHigh fiber diet

Home w/ f/uHome w/ f/u

ED management: DiverticulitisED management: Diverticulitis

ABC’sABC’sSpectrum: well to extremely sickSpectrum: well to extremely sick

NPONPOIV AntibioticsIV Antibiotics

Cipro & flagylCipro & flagylAmp, gent, flagylAmp, gent, flagylClinda & flagylClinda & flagyl

Conservative medical management or Conservative medical management or surgical managementsurgical management

Medical or surgical Tx?Medical or surgical Tx?

No uniform consensusNo uniform consensusLiterature generally supports conservative Literature generally supports conservative

Tx for all 1Tx for all 1stst episode episode80% recover & only 7-35% recur80% recover & only 7-35% recurGenerally will only operate after 2Generally will only operate after 2ndnd episode episodeExceptions areExceptions are

Complicated diverticulitis more likely to require Complicated diverticulitis more likely to require surgery or percutaneous drainagesurgery or percutaneous drainage

Immunocompromised ptsImmunocompromised pts

Surgical TxSurgical Tx

Perforated diverticulitisPerforated diverticulitisPrimary sigmoid resection w/Primary sigmoid resection w/

Primary anastomosis in milder casesPrimary anastomosis in milder casesColostomy & mucous fistula in sicker ptsColostomy & mucous fistula in sicker pts

Mortality rates vary w/ severityMortality rates vary w/ severity0-6% Stage I0-6% Stage I35-64% Stage IV35-64% Stage IV

DispositionDisposition

Mild cases w/ reliable f/u & no evidence of Mild cases w/ reliable f/u & no evidence of perforation may be treated as outpatientsperforation may be treated as outpatients

Everybody else (most pts) should be Everybody else (most pts) should be admittedadmittedSurgical consultSurgical consult