Surgery Case Surgery Case PresentationPresentation

By: Jennifer Distinti PA-SBy: Jennifer Distinti PA-S

Presented to: Prof. AcevedoPresented to: Prof. Acevedo

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 SBH ER on 10/20/00 presented to the SBH ER on 10/20/00 at 10:00 p.m.with a c/o of painless at 10:00 p.m.with a c/o of painless rectal bleeding starting 5 days ago, on rectal bleeding starting 5 days ago, on and off. Patient stated that her and off. Patient stated that her clothes were soaked with blood. She clothes were soaked with blood. She admitted to noticing bright red blood admitted to noticing bright red blood in her stool.in her stool.

Continued...Continued...

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 1999- 1999- Diverticulosis-Diverticulosis- no surgical no surgical

Tx.Tx. 1993- 1993- Polyps, bleedingPolyps, bleeding- received - received

blood blood transfusion. 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: AOx3 NADAOx3 NAD

Skin:Skin: Clear/noClear/no rashesrashes

HEENT:HEENT: No abn. findingsNo abn. findings

Thyroid:Thyroid: Not enlarged on Not enlarged on

palpationpalpation

Lungs:Lungs: CTABL no w/r/rCTABL no w/r/r

Cardiac:Cardiac: SS11SS22 r/r/r r/r/r

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 Tagament 300mg IV q 8 hrs.Tagament 300mg IV q 8 hrs. Monitor labs. (H&H)Monitor labs. (H&H) Consult GI: sigmoidoscopy/colonoscopyConsult GI: sigmoidoscopy/colonoscopy

Anatomy of the Colon:Anatomy of the Colon:

Anatomy of The Colon:Anatomy of The Colon:

The colon averages 180cmThe colon averages 180cm– Ascending: 8 inchesAscending: 8 inches– Descending: 12 inchesDescending: 12 inches– Transverse: 18 inchesTransverse: 18 inches– Sigmoid: 18 inchesSigmoid: 18 inches– The cecum is the first portion of the The cecum is the first portion of the

large bowel and it joins to the small large bowel and it joins to the small bowel.bowel.

Parts of the Right & Left Parts of the Right & Left Colon as Well as there Blood Colon as Well as there Blood

Supply:Supply: Right Colon:Right Colon: --->Superior Mesenteric Artery --->Superior Mesenteric Artery

– CecumCecum– AscendingAscending--->Rt. Colonic Artery--->Rt. Colonic Artery– Hepatic FlexureHepatic Flexure--->Middle Colonic Artery--->Middle Colonic Artery– Proximal Transverse ColonProximal Transverse Colon--->Middle Colonic Artery--->Middle Colonic Artery

Left Colon:Left Colon: --->Inferior Mesenteric Artery --->Inferior Mesenteric Artery– Distal Transverse ColonDistal Transverse Colon--->Lt. Colonic Artery--->Lt. Colonic Artery– Splenic FlexureSplenic Flexure– Descending ColonDescending Colon--->Lt. Colonic Artery--->Lt. Colonic Artery– Sigmoid ColonSigmoid Colon--->Sigmoid Artery--->Sigmoid Artery– RectosigmoidRectosigmoid

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 transverse the splenic flexure to proximal transverse with blood clots but no active bleeding. with blood clots but no active bleeding. Internal hemorrhoids found as well.Internal hemorrhoids found as well.

Recommendation:Recommendation:

1. Surgery on 10/24/00 for subtotal 1. Surgery on 10/24/00 for subtotal colectomy.colectomy.

2. Monitor CBC2. Monitor CBC

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

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)

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.

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 was She had + BS and she was having loose stools which was expected. Her vitals remained stable and she was in expected. Her vitals remained stable and she was in good spirit. The rest of her physical exam was normal. good spirit. The rest of her physical exam was normal. The incision had no signs of erythema, edema, infection The incision had no signs of erythema, edema, infection or discharge and we removed the staples on post op day or discharge and we removed the staples on post op day #8. She was put on a low residue/lactose free diet. PT #8. She was put on a low residue/lactose free diet. PT was call to start the patient ambulating and depending was call to start the patient ambulating and depending on her H&H and whether or not blood was found in her on her H&H and whether or not blood was found in her stool, she would be discharged on 11/03/00, which she stool, she would be discharged on 11/03/00, which she was.was.

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 associated with a A decrease in fiber in the diet is associated with a high incidence of diverticulosis in Western high incidence of diverticulosis in Western population.population.– One thought is that when circular muscular contractions One thought is that when circular muscular contractions

occur in pts. with small amounts of stool in the colon, the occur in pts. with small amounts of stool in the colon, the colon lumen becomes occluded.colon lumen becomes occluded.

– When two contractions occur close to one another the When two contractions occur close to one another the lumen of the intervening segment of the colon is isolated lumen of the intervening segment of the colon is isolated from the rest of the colon and high pressure is generated from the rest of the colon and high pressure is generated in that segment.in that segment.

– Increased pressure results in the formation of diverticula Increased pressure results in the formation of diverticula by placing increased tension on the colon wall.by placing increased tension on the colon wall.

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

THE ENDTHE END