CASE BASED LEARNING

ABDOMINAL INTRODUCTION

Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia - QUADRANTS ABDOMEN- ORGANS - CAUSES ABDOMINAL PAIN- CAUSES

of a viscus  Perforation of a viscus  Obstruction of a viscus  Infarction of a viscus  Intra-abdominal hemorrhage or retroperitoneal hemorrhage  Extra-abdominal or medical causes for acute abdominal pain like lower lobe pneumonia and inferior wall MI ABDOMINAL PAIN- HISTORY

SOCRATES = Nemonic

S - site  “S” stands for “site”. Which region/quadrant? Is O - onset it a general sense of overall discomfort? The site C - characteristics of pain helps you fine tune your subsequent R - radiation physical exam and diagnostic decision making. A – associated symptoms &  “O” stands for “onset”. When did the pain start? signs Acute or insidious? T - timing  “C” stands for “characteristics”. The pain may E - exacerbating/ be sharp, dull, heavy, etc. or a combination of alleviating descriptions. S - severity ABDOMINAL PAIN- HISTORY

SOCRATES = Nemonic  “R”, which represents “radiation”. Ask if the pain stays at the site they are describing or if it S - site travels somewhere else in the body. Ex:Ureteric O - onset C - characteristics  A” stands for associated symptoms. What other R - radiation symptoms are present and associated with the A – associated symptoms & pain? Ask do they also have and/or signs ? T - timing  "T" stands for timing. When does the pain E - exacerbating/ occur? Does it happen at specific times of the alleviating day, or is it constant? S - severity ABDOMINAL PAIN- HISTORY

SOCRATES = Nemonic  “E” represents “exacerbating” factors; grouped S - site within this is also alleviating factors. The O - onset patient should be probed as to what makes their C - characteristics pain better or worse. Certain physical positions, R - radiation medications, etc. These factors can all provide A – associated symptoms & historical clues about the root cause. signs  “S” stands for “severity”. In most hospitals this T - timing is formulated on a 1 to 10 scale with 10 being E - exacerbating/ the most severe pain they’ve ever experienced. alleviating S - severity ABDOMINAL PAIN

Somatic pain: Visceral pain: Originate from internal organs Originate from abdominal wall and visceral and parietal peritoneum Achy and crampy Sharper and more distinct Variable localization and Better localized sensation Sensitive to cutting,tearing, Not sensitive to cutting, tearing, burning and crushing burning or crushing Sensitive to stretching of walls of hollow organs and capsule of solid organs ABDOMINAL PAIN

Shifting pain: Ex: Periumbilical pain shifting to RLQ in Ac.

Radiating pain: Ex: Pain radiating from loin to groin in ureteric colic

Reffered pain: Ex: Pain felt at Lt shoulder in case of splenic rupture ABDOMINAL PAIN- GRADING

It is done by comparing a10cm line numbered 0 to 10 and this is called Visual Analogue Scale- VAS Minimum 0 means no pain 2 is mild pain 4 is discomforting pain 6 is distressing pain 8 is intense pain

CASE BASED LEARNING

ABDOMINAL PAIN RLQ PAIN

Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia ABDOMINAL PAIN- RLQ PAIN A 28-year-old female presents with a 2-day hx of vague periumbilical pain. Today the patient has lower abdominal pain (right greater than left), which is associated with new onset of urinary frequency. She also vomited twice today. She is sexually active and her menstrual cycle tends to be irregular. Her last menstrual period was 6 weeks ago (2 weeks late).

VS: T = 100.2, HR = 90, BP = 110/68. Labs: H/H = 12.0/36.3, WBC = 11,300, U/A: 5 RBCs, 10–15 WBCs

Physical examination: RLQ tenderness, guarding, and rebound. Pelvic examination without cervical motion tenderness

What would be your differential dx and plan for further evaluation? RLQ PAIN- Differential Diagnosis

D/D in Adult males RLQ PAIN- Differential Diagnosis

D/D in Females

D/D in Children ABDOMINAL PAIN- RLQ PAIN

 This patient has the characteristic prodrome for appendicitis with periumbilical pain migrating to the RLQ and associated with localized peritoneal findings.  Check the β-hCG before proceeding with appendectomy particularly in light of the patient’s delayed menstrual period. Ectopic pregnancy must be r/o.  The abnormal U/A result may relate to bladder irritation from an inflamed or represent the additional problem of a UTI.  Though the clinical picture is most consistent with appendicitis, preoperative USG/CT Abd should be done if the β-hCG is normal.

 Diagnostic Priorities: Ac Appendicitis, R/O UTI and ectopic pregnancy. RLQ PAIN- Ac. Appendicitis

 History- Symptoms  • (hamburger sign), nausea, vomiting  • Vague periumbilical pain that shifts to the RLQ- “ Murphy’s Triad”  Physical Exam- Signs  • McBurney’s point tenderness and rebound tenderness  • Cutaneous hyperesthesia, Rovsing’s, psoas, and obturator signs  Laboratory  • Elevated WBC with left shift  • C-reactive protein  • Pregnancy test  • Urinalysis: sterile pyuria RLQ PAIN- Ac. Appendicitis  Diagnosis  • Oftentimes is a clinical diagnosis  Pathophysiology  • Closed-loop obstruction  • Fecolith in adults, lymphoid hyperplasia in children  Imaging  • None needed with classic H&P and  • US: women and children  • Avoid CT in children (increased risk of malignancy) and pregnancy (risk to fetus)  • CT: if diagnosis is equivocal in men and nonpregnant women  • MRI: pregnant women  Management  • Appendectomy (open or laparoscopic) RLQ PAIN- Ac. Appendicitis

 USG Abdomen:  Tubular structure  More than 6mm in diameter  Non compressible

CT Abdomen: Thickened appendix Fecolith Fat stranding ALVARADO SCORING Ac. Appendicitis- Algorithm

CASE BASED LEARNING

ABDOMINAL PAIN RUQ PAIN- 1

Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia ABDOMINAL PAIN- RUQ PAIN

HISTORY: A 40-year-old moderately obese female presents to the emergency department with a 1-day history of constant epigastric and right upper quadrant (RUQ) pain. She describes the severity of the pain as a 7 out of 10. The pain began after eating fried pork. She reports that the pain also seems to affect the right side of her back near her scapula. She feels nauseated and has vomited twice. She has had similar pain, but of lesser severity, about once a month for the past year. The pain comes on after eating fried or spicy foods, but previously it has resolved after an hour. She is gravida six and para six. ABDOMINAL PAIN- RUQ PAIN

On physical examination, her temperature is 100 °F, heart rate is 110/min, and her blood pressure is 120/80 mmHg. She has marked tenderness in the RUQ of the abdomen to palpation. When the RUQ is palpated while she is taking a deep breath, she abruptly ceases inspiration secondary to pain Murphy’s Sign+ve

Laboratory values are significant for WBC count of 14 × 10 3 /μL (normal 4.1–10.9 × 10 3 /μL), Total Bilirubin 1.0 mg/dL (0.1–1.2 mg/dl), Alkaline phosphatase70 units/L (33–131 u/L), Amylase 60 units/L (30–110 u/L), and Lipase 30 units/L (7–60 u/L).

What would be your differential dx and plan for further evaluation? RUQ PAIN- Differential Diagnosis ABDOMINAL PAIN- RUQ PAIN

 With her current history of severe persistent abdominal pain following ingestion of fatty foods, nausea and vomiting, and associated right upper quadrant tenderness to palpation, the etiology is most likely of biliary origin.  The patient’s prior history is consistent with symptomatic cholelithiasis  With a positive Murphy’s sign, , tachycardia, and elevated WBC count, the most likely current diagnosis is acute .  With a normal total bilirubin and alkaline phosphatase, choledocholithiasis and acute cholangitis are less likely.  Similarly, a normal amylase and lipase rule out . RUQ PAIN- Ac. Cholecystitis

 History  • RUQ pain in obese, multiparous female  Physical Exam  • Murphy’s sign for acute cholecystitis  Pathology/Pathophysiology  • Acute cholecystitis triggered by persistent cystic duct obstruction by gallstone  Diagnosis  • RUQ US: , pericholecystic fluid, thickened gallbladder wall, and sonographic Murphy’s sign  • HIDA scan if RUQ ultrasound is nondiagnostic  • KUB not helpful: only 10 % of gallstones are radio-opaque RUQ PAIN- Ac. Cholecystitis

Manifestations of Gall Stones RUQ PAIN- Ac. Cholecystitis

Biliary Colic Vs Ac Cholecystitis RUQ PAIN- Ac. Cholecystitis  Management  • Asymptomatic gallstones: cholecystectomy not indicated  • Symptomatic cholelithiasis (biliary colic): elective lap cholecystectomy  • Acute cholecystitis: urgent (within 48 h) lap cholecystectomy  • Acute acalculous cholecystitis: cholecystostomy tube if critically ill  • Emphysematous cholecystitis: emergent cholecystectomy  • Gallstone : remove large impacted gallstone from terminal (leave gallbladder alone)  Postoperative  • If a patient presents within the first week after cholecystectomy with abdominal pain, distention, and anorexia, consider a biloma (cystic duct stump leak, CBD injury)  • Cystic duct stump leak readily treated with ERCP and stenting of the sphincter of Oddi  • CBD injury may require hepaticojejunostomy/choledochojejunostomy RUQ PAIN- Ac. Cholecystitis

 Additional Important Facts  • Ursodeoxycholic acid could be employed as conservative management for patients with cholelithiasis  • Calcified gallbladder (porcelain): increased risk of malignancy, perform cholecystectomy  • Choledochal cysts are congenital dilations of the biliary tree; prone to cholangitis, risk of associated malignancy, need to excise (if intrahepatic ducts are involved (Caroli’s disease), and may need transplantation  • Hemolytic anemia in childhood: high risk of black pigment gallstones  • Gallbladder cancer: associated with gallstones  • Gallbladder polyps: > 1 cm suspicious for cancer; >2 cm high likelihood of cancer RUQ PAIN- Ac. Cholecystitis

 Cholesterol gallstones form when the concentration of cholesterol in the bile exceeds its solubility

 Black stones are often associated with hemolytic disease “Gall Stone is the  Brown stones usually are tombstone erected in the associated with bacterial memory of dead bacteria infection and parasites inside” RUQ PAIN- Ac. Cholecystitis

USG Abdomen: Hyperechoic Gall stone shadow Posterior acoustic shadowing GB wall thickness > 3mms Pericholecystic fluid collection

HIDA Scan: Fig 1: Visualisation of GB Fig 2: Non visualization of GB- Acute Cholecystitis

CASE BASED LEARNING

ABDOMINAL PAIN RUQ PAIN- 2

Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia ABDOMINAL PAIN- RUQ PAIN HISTORY: A 40-year-old female presents with a 24 hour history of right upper quadrant (RUQ) and epigastric pain, associated with nausea and vomiting. She has had similar pain in the past, particularly after eating greasy foods. According to her family, over the last few hours, the patient has become slightly confused. Past medical history is negative.

PHYSICAL EXAM: Temperature of 102.5 °F, a heart rate of 110 beats/min, respiratory rate of 16/min, and a blood pressure of 90/60mmHg. She is moderately tender in the RUQ to deep palpation. She has slight scleral icterus. She has noted dark- colored Urine. The remainder of her abdominal exam is negative. ABDOMINAL PAIN- RUQ PAIN

Laboratory Values: White blood count of 15 × 10 3 /μL (normal 4.1–10.9 × 10 3 /μL), Total bilirubin of 4.0 mg/dl (0.1–1.2 mg/dl), Alkaline phosphatase (AP) of 350 μ/L (33–131 μ/L), Aspartate aminotransferase (AST) of 300 μ/L (5–35 μ/L) Alanine aminotransferase (ALT) of 280 μ/L (7–56 μ/L), Gamma-glutamyl transpeptidase (GGT) of 330 μ/L (8–88 μ/L), Amylase of 100 μ/L (30–110 μ/L). Urine is positive for bilirubin.

What would be your differential dx and plan for further evaluation? RUQ PAIN- Differential Diagnosis ABDOMINAL PAIN- RUQ PAIN  The most likely diagnosis in a patient with a 1-day history of RUQ pain worsened with greasy foods, nausea, , and fever is acute cholangitis secondary to gallstone impaction Charcot’s Triad

 Additionally, she has leukocytosis, hypotension, altered mental status, elevated bilirubin, and deranged liver function tests, all of which are consistent with the suppurative cholangitis Reynold’s Pentad

 The Tokyo guidelines have been proposed as diagnostic criteria for acute cholangitis. Patients should have evidence of systemic inflammation (fever and/or leukocytosis), (jaundice and/or abnormal liver enzymes), and biliary obstruction (dilated bile ducts on ultrasound). RUQ PAIN- History and Physical • Charcot’s triad RUQ pain, fever and jaundice • Reynold’s pentad + hypotension and altered mental status • Look for evidence of SIRS • Elderly patients may be hypothermic and leukopenic (are relatively immunosuppressed)

Etiology/Pathophysiology • Biliary obstruction with bacterial infection • Bacteria enter bile either via bloodstream from the portal vein or retrograde from the • Most commonly caused by gallstone obstruction of the distal CBD • Other causes: biliary stricture, cancer, parasites • Suppurative cholangitis: acute cholangitis complicated by septic shock RUQ PAIN- Ascending Cholangitis Diagnosis

• Elevated WBC • AP, ALT, AST, GGT rise proportion • US: dilated CBD Management • Aggressive IV fluids, blood cultures, broad-spectrum antibiotics • Admit to ICU • Urgent biliary decompression via ERCP • PTC if ERCP fails PTBD • Open surgery (insert T-tube into CBD) if PTC fails • Cholecystectomy after sepsis resolves to prevent further biliary complications Watch Out • The diagnosis of acute cholangitis may be missed in the elderly and immunosuppressed (e.g. steroids) • Think sclerosing cholangitis if also having symptoms of IBD RUQ PAIN-Ascending cholangitis RUQ PAIN-Ascending Cholangitis

ERCP ERCP- Stone Extraction

PTBD

EUS ERCP- Stent Placement

CASE BASED LEARNING

ABDOMINAL PAIN EPIGASTRIC PAIN- 1

Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia ABDOMINAL PAIN- EPIGASTRIC PAIN- 1

HISTORY:

A 56-year-old male with a history of gastroesophageal reflux disease (GERD), hypertension, and diabetes presents to the emergency room complaining of severe upper central abdominal pain. The patient reports epigastric pain for months, but it has just acutely become intolerable over the last 8 hrs. He states that the chronic pain has been a “gnawing” pain that comes on after eating. He thought he was just having some and would take some antacids for relief. Late last night, the pain became excruciating and now he is having trouble moving. ABDOMINAL PAIN- RUQ PAIN

On physical examination, blood pressure is 130/70 mmHg, heart rate is 110 bpm, and temperature is 101.5 °F. He appears to be in severe distress secondary to pain. The patient refuses to straighten his legs because it hurts too much. He almost jumps off of the table when you press on his abdomen. He has diffuse guarding and rebound tenderness.

Laboratory values: WBC of 15 (normal 4.1–10.9 × 10 3 /μL), BUN of 35 (7–20 mg/dL), creatinine of 1.8 (0.5–1.4 mg/dL), serum amylase of 70 (30–110 μ/L), and lipase of 60 (7–60 u/L).

An upright CXR demonstrates free air under the right diaphragm.

What would be your differential dx and plan for further evaluation? Epigastric Pain- Differential Diagnosis ABDOMINAL PAIN- Epigastric Pain

✓ The free air under the diaphragm indicates that the patient has a perforated viscus. ✓ This is supported by evidence of diffuse on physical exam. ✓ The most common causes of free air under the diaphragm are perforated ulcers and perforated . ✓ Given the longstanding history of epigastric pain relieved by antacids, the most likely diagnosis is a perforated ulcer Epigastric Pain- DU perforation

✓ History and Physical: ✓ Sudden onset severe epigastric pain that becomes diffuse ✓ History of (PUD), H. pylori, smoking, chronic NSAID use ✓ Evidence of SIRS ✓ Patient lying motionless in bed ✓ , rigidity, and rebound tenderness ✓ Pathophysiology: ✓ Acid hypersecretion, defective mucosal defense or H.Pylori infection ✓ Five types of gastric ulcers- Modified Johnson’s classification ✓ Type I ulcers are on the lesser curve of the stomach ✓ Type II ulcers are in the stomach and duodenum ✓ Type III ulcers are pre-pyloric ✓ Type IV ulcers are located proximally near the cardia ✓ Type V ulcers are anywhere secondary to NSAID use Epigastric Pain- DU perforation

✓ Workup: ✓ Leukocytosis with left shift ✓ Upright CXR: free air under diaphragm ✓ CT with oral gastrografin ✓ Management: ✓ Duodenal perforation ✓ – Primary closure with an omental patch ✓ Gastric perforation ✓ – Primary closure, biopsy, omental patch vs. wedge resection ✓ – Must rule out malignancy ✓ Triple therapy: clarithromycin, amoxicillin, and a PPI for 14 days (if H. pylori positive) ✓ Additional acid reduction surgery rarely needed Epigastric Pain- DU perforation

Pneumoperitoneum DU Perforation Graham’s Patch- Omentopexy

CASE BASED LEARNING

ABDOMINAL PAIN EPIGASTRIC PAIN- 2

Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia ABDOMINAL PAIN-Epigastric Pain HISTORY: A 41-year-old woman presents to the emergency department complaining of severe and continuous epigastric pain for the past 24 hours. The pain radiates straight through to her back. She has had progressive nausea with vomiting. The vomitus is bile stained without blood. She has had similar but less severe episodes in the past, usually after eating heavy meals, but they always resolved within a few hours. She is married, with two children, and does not consume any alcohol. PHYSICAL EXAM: On exam, she is afebrile, heart rate is 115/min, blood pressure is 128/86 mmHg, and she has a normal respiratory rate. Her abdomen is not distended. She has no surgical scars on her abdomen and no obvious masses visible. She has no bruising around her umbilicus or along her flank. Bowel sounds are hypoactive. She has marked tenderness to palpation in her epigastrium, without guarding or rebound. The remainder of her abdomen is soft and non-tender to palpation. No masses or are appreciated. ABDOMINAL PAIN-Epigastric Pain

Laboratory Values: WBC count of 17.2 × 10 3 cells/μL (normal 4.1–10.9 × 10 3 cells/uL), Amylase of 1,545 u/L (normal 30–110 u/L), Lipase of 1,134 u/L (normal 7–60 u/L), ALT of 245 u/L (7–56 u/L), AST of 263 u/L (5–35 u/L), Serum glucose of 156 mg/dl (65–110 mg/dL), and LDH 180 u/L (0–250 u/L)

An abdominal series demonstrates gas throughout the small and large bowel, and a focal dilated loop of proximal small bowel without air fluid levels- sentinel loop++. There is no free air under the diaphragm.

What would be your differential dx and plan for further evaluation? EPIGASTRIC PAIN- Differential Diagnosis ABDOMINAL PAIN-Epigastric Pain

✓ Diagnosis most probably ✓ This patient has the classic presentation which consists of epigastric abdominal pain radiating straight through to the back with nausea and vomiting. ✓ She has had prior episodes of pain, which have resolved within a few hours, after eating heavy meals, which is characteristic of symptomatic gallstones. ✓ Since the vast majority of pancreatitis cases are due to gallstones or alcohol and this patient does not consume alcohol, we can conclude that her symptoms are most likely related to gallstones. ✓ Finally, the amylase and lipase are elevated Epigastric Pain-Acute Pancreatitis

History and Physical • Nonsurgical conditions that mimic an : , acute adrenal insufficiency, sickle cell crisis, diabetic ketoacidosis, acute porphyria, pelvic inflammatory disease, kidney stones, and pyelonephritis • Patients with pancreatitis typically present with epigastric pain radiating to the back, nausea, vomiting, anorexia, fever,tachycardia.

Pathophysiology • The initial event in pancreatitis is the inappropriate activation of pancreatic enzymes • Gallstones and alcohol are the most common causes of acute pancreatitis Epigastric Pain-Acute Pancreatitis

Diagnosis • Most cases can be diagnosed with just a history, physical, and abnormal amylase/lipase • Ranson criteria are used to predict severity based on parameters during initial admission and at 48 hours after

Workup • Amylase/lipase levels do not correlate with severity of pancreatitis • In the absence of a history of alcohol abuse, start with a RUQ ultrasound to look for gallstones Epigastric Pain-Acute Pancreatitis

Management • Patients should initially be managed conservatively with IV fluids, NPO, and narcotic analgesia • Gallstones – urgent ERCP if concomitant cholangitis – early cholecystectomy if mild pancreatitis – late cholecystectomy if severe pancreatitis • If patients do not clinically improve after 3 days of conservative management, get a CT scan with contrast to look for any underlying complications (i.e., necrosis) • Begin enteral nutrition in patients with prolonged NPO status or in severe acute pancreatitis • Refractory persistent abdominal pain is the main indication for surgery in Epigastric Pain-Acute Pancreatitis

Etiology Complications “I GET SMASHED”: • Systemic Idiopathic – Early (1st week) Gallstones – Multi-organ failure Ethanol • Local Trauma – Late (3 weeks) Scorpion bite – Mumps (viruses) – Autoimmune – Pancreatic necrosis Steroids Hyperlipidemia ERCP Drugs Acute Pancreatitis- Ranson’s Scoring

At Admission After 48 hrs

“GA LAW (Georgia law)”: “C HOBBS (Calvin and Glucose >200 Hobbes)”: Age > 55 Calcium <8 mg/dL LDH > 350 Hct drop of >10% AST > 250 O2 <60 (PaO2) WBC > 16,000 Base deficit >4 Bun >5 increase Sequestration >6 L Acute Pancreatitis- Glasgow- Imrie Scoring Acute Pancreatitis- Balthazar Scoring Acute Pancreatitis- BISAP Scoring Acute Pancreatitis- AXR Acute Pancreatitis- CECT

Acute Pancreatitis / Pancreatic Necrosis CECT: Acute Pancreatitis Phlegmon / Inflammatory Mass Arrow: No enhancement of pancreas White arrowheads: Phlegmon with IV contrast Diffusely enlarged pancreas with low Black arrowhead: Pancreatic calcification Arrowheads: Normal enhancement in density from Large Arrow: Peripancreatic fascial the tail of Pancreas. infiltration

CASE BASED LEARNING

ABDOMINAL PAIN LLQ Pain - 1

Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia ABDOMINAL PAIN-LLQ Pain HISTORY: A 55-year-old obese female presents with a 2-day history of left lower quadrant pain, nausea, anorexia, and low-grade fever. The patient states that the pain is constant, moderately severe, and does not radiate anywhere. No H/O aggravating/relieving factors. She denies vomiting and bloody or black stools and has no recent change in bowel habits, though she says she’s been constipated most of her life. She has noted similar pain in the past,but never this severe, and has never sought medical attention before. She has never had a screening colonoscopy or prior surgery. PHYSICAL EXAM: Abdominal exam reveals mild distention, no surgical scars, and no masses. Bowel sounds are absent. The left lower quadrant is moderately tender to palpation with guarding and no rebound tenderness. Rectal exam is unremarkable. Pelvic exam reveals no cervical motion tenderness and no adnexal masses. LABS: TWBC- 16,000; Hb-13Gm; Hct- 39% What would be your differential dx and plan for further evaluation? LLQ PAIN- Differential Diagnosis ABDOMINAL PAIN-LLQ Pain

 Diagnosis most probably Acute Diverticulitis  Given the patient’s left lower quadrant (LLQ) pain and tenderness on exam, associated with fever and leukocytosis, acute diverticulitis is the most likely diagnosis.  Obesity, diet low in fiber and high in fat and red meat, and advanced age are risk factors for the formation of .  Rectal diverticula are extremely rare. It is hypothesized that they almost never occur because the taenia coli, the longitudinal bands of smooth muscle along the colon, unite into a circumferential band around the , thereby eliminating points of weakness that precede a diverticulum. LLQ Pain-Acute Diverticulitis History and Physical • Major risk factors are obesity, advanced age, and diet low in fiber, high in fat and red meat • Diverticulitis is a clinical diagnosis (LLQ pain and tenderness, fever, leukocytosis) Pathophysiology • The sigmoid colon is the most common site • Complicated diverticulitis: abscess, free perforation, fistula, stricture, and obstruction Diagnosis • CT scan is the first-line imaging modality • Avoid barium enema and colonoscopy in acute presentation because of increased risk of perforation • Determine if complicated or uncomplicated and with or without SIRS LLQ Pain-Acute Diverticulitis Management • Uncomplicated diverticulitis without SIRS – Treated as outpatient – Oral antibiotics and clear liquids • Uncomplicated diverticulitis with SIRS – Admit to hospital – NPO, IV fluids, IV antibiotics, and analgesia – Follow up with colonoscopy 4–6 weeks after acute episode to rule out malignancy and Inflammatory Bowel Disease. LLQ Pain-Acute Diverticulitis

Management • Complicated diverticulitis usually requires surgery – Resect the affected colon and construct end colostomy if urgent – Sigmoid colectomy with primary anastomosis if not urgent LLQ Pain-Acute Diverticulitis - Etiopathogenesis • l .Colonic diverticula are mucosal out pouchings through the submucosa and the muscular layer of the colon. • 2 .They occur most commonly in the sigmoid colon, and in 10% of patients, they involve the entire colon. • 3.A disorder of modern civilization and is associated with consumption of refined food products. It is rare in rural African and Asian populations where dietary fiber is high. • 4. Long standing increases the stool transit time and intraluminal pressure and causes diverticulosis. • 5. They arise between antimesenteric taenia and the mesenteric taenia at the site of entry of the blood vessels.

CASE BASED LEARNING

ABDOMINAL PAIN LLQ PAIN- 2

Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia ABDOMINAL PAIN- LLQ Pain

HISTORY: An 80-year-old male presents with severe abdominal distention and no bowel movement or gas per rectum for 3 days, as well as recent onset of vomiting. He has Parkinson’s disease and chronic constipation and lives in a nursing home. His medications include levodopa and benztropine, which he has been taking for several years. PHYSICAL EXAM: Patient’s vital signs are T 37°C, heart rate 90/min, blood pressure 116/70 mmHg, and respiratory rate 22/min. Patient is tachypnic but nontoxic, with mental status unaltered. His abdomen is severely distended. He does not have any abdominal surgical scars. He is tympanitic but has no significant tenderness to palpation. There are no palpable , and rectal exam demonstrates an absence of stool with no palpable masses or strictures. ABDOMINAL PAIN- LLQ Pain

LABS: BUN 26 mg/dL; Creatinine 1.4 mg/dL, Electrolytes within normal limits, TWBC:6800/dL; ABG- pH 7.48//PaCO2 30//PaO2 80//HCO3 24//SpO2 99 %. IMAGING: Plain upright abdominal radiograph shows a massively dilated loop of sigmoid with the apex pointing toward the right upper quadrant, consistent with the “coffee bean” or “bent-inner tube” sign; upright chest radiograph shows no free air under the diaphragm. What would be your differential dx and plan for further evaluation? LLQ PAIN- Differential Diagnosis ABDOMINAL PAIN-LLQ Pain

 Diagnosis most probably Sigmoid  The massive, slowly progressive abdominal distention, combined with obstipation, and X-ray findings are consistent with large . The radiologic appearance is most consistent with a sigmoid volvulus.  Large bowel obstruction-LBO- is more likely to be associated with more pronounced distention, less or late onset vomiting, and decreased bowel sounds.  Small bowel obstruction- SBO- SBOs tend to be associated with more pronounced vomiting. In an early SBO, bowel sounds are hyperactive, with “rushes and tinkles”- Borborygmi. In late SBO- absent bowel sounds- silent abdomen. LLQ Pain- Sigmoid Volvulus History and Physical • LBO – gradual and severe abdominal distention, obstipation, and vomiting • Uncomplicated volvulus – normal vitals, normal mental status, and non-tender abdomen • Complicated volvulus – severe abdominal pain, fever, tachycardia, toxic appearance, peritoneal signs, and leukocytosis • Look for abdominal scars and hernias and perform a rectal exam to assess other differential diagnoses Etiology/Risk Factors: • Most common causes of LBO: Cancer, Diverticulitis & Volvulus • Sigmoid Volvulus – acquired stretching of the sigmoid – Neuropsychiatric disease, institutionalization, chronic constipation, long-term anticholinergic use, highfiber diet, and pregnancy • Cecal Volvulus – congenital failure of fixation of the cecum LLQ Pain- Sigmoid Volvulus Diagnosis • Compared to LBO, SBO has faster onset and more likely to cause vomiting and high-pitched bowel sounds • Patients with Ogilvie’s syndrome are more likely to be already hospitalized and bedridden, often in the postoperative setting • Abdominal X-ray – Sigmoid volvulus –“coffee bean”, “omega”, or “bent inner tube”, “kidney-bean” sign – Cecal volvulus –“comma” or “kidney bean” sign- Human embryo sign • CT scan if equivocal X-ray findings • Contrast enema may be diagnostic (“bird’s beak” sign) and therapeutic in reducing the volvulus – Water-soluble contrast (Gastrografin) rather than barium, to avoid peritonitis and scarring in case of perforation – Bowel wall thickening, mesenteric edema, pneumatosis, and portal venous gas suggest ischemic bowel

LLQ Pain- Sigmoid Volvulus

Management • Therapy differs based on the location and severity of complication – Uncomplicated sigmoid volvulus – endoscopic detorsion followed by semi-elective resection – Complicated sigmoid volvulus – no detorsion attempted; emergent laparotomy with resection – Cecal volvulus – no detorsion attempted; take to OR for right colectomy • Complications of surgery – wound infection, anastomotic leak, and recurrence. Without detorsion or resection – ischemia, perforation, and sepsis