To operate or not to operate?
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Transcript of To operate or not to operate?
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To operate or not to operate?
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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.
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• 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.
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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
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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.
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Plan
• Admitted under the medical care.
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2 days later
● developed sudden abdominal pain with vomiting.
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Surgical consult
● O/E: BP 95/52, HR 78, Temp 36, SpO2 96% Distended Abdomen, Generalised tenderness with central guarding.
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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
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Provisional surgical diagnosis :
● Acute abdomen
?? Ischaemic bowel
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● What would you do??
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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.
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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.
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Procedure
• Thickened loop of small bowel was resected with primary side to side anastomosis done.
● General peritoneal lavage.
● Pelvic drain.
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Small bowel diverticula
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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 %
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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.
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Classification
● Intraluminal or extraluminal.
● Intraluminal diverticula and Meckel diverticulum are congenital.
● Extraluminal diverticula
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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
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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.
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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,
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● Hemorrhage and pancreaticobiliary disease are the most common complications of duodenal diverticulum,
● Diverticulitis and perforation are more common with jejunoileal diverticula.
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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.
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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
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Investigations
● Lab tests: limited value
● Radiological.
● Endoscopy.
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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
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References
● Emedicine.com● Uptodate● Butler et al.Journal of Medical Case Reports 2010
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● Thank you..