NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

of choice is ileostomy with formation of a Hartmann pouch of the rectum and total abdominal colectomy (see Fig. 8-8). This procedure, which leaves the rectum intact, may not cure the patient or remove the risk of cancer. Therefore, further discussion of manage- ment and subsequent definitive surgery is necessary once the patient recovers. Case Variation 8.12.2. Air in the wall of the colon ◆ ◆ This also is a sign of impending perforation, and the patient may require operative intervention. The Hartmann procedure is used (see Case Variation 8.7.12). Case Variation 8.12.3. Significant improvement over the next several days ◆ ◆ With improvement in the patient’s condition, emergent surgery can be avoided. Case Variation 8.12.4. No changes over the next several days ◆ ◆ If the patient fails to improve, surgery is appropriate. Case Variation 8.12.5. A persistent, stormy course with worsening fever, leukocytosis, and pain ◆ ◆ The patient is not responding to medical management, and surgery is necessary.

DISORDERS OF THE COLON

Case 8.13 Right Lower Quadrant Pain You see a 25-year-old woman in the emergency department for abdominal pain, which has been present for 12 hours. The pain began in the middle abdomen, and it has now migrated to the lower abdomen on the right side. The patient has anorexia. On physical examination, the only finding is mild pain without guarding or rebound tenderness in the RLQ. Laboratory studies and abdominal radiographs are normal, and a pregnancy test is negative. Q: What evaluation is appropriate? A: You should be suspicious for appendicitis as well as a gynecologic problem. Part of the physical examination should include rectal and pelvic examinations. A rectal examina- tion can detect pain in the right pelvis due to retrocecal appendicitis ( Fig. 8-12 ). The pelvic examination can detect ovarian pathology and pelvic inflammatory disease. If these parts of the examination are normal, management with hydration, NPO feeding, and observation with serial examinations, including a repeat complete blood count (CBC), is appropriate. Exploration with these mild symptoms is not appropriate. To avoid masking the progression of symptoms, pain medication should be avoided. Most surgeons would also obtain an abdominal ultrasound to allow visualization of the fallopian tubes and ovaries to rule out gynecologic pathology. Some physicians would per- form a CT scan of the abdomen to diagnose appendicitis, such as dilated appendix, thick- ened wall, intimation and fat stranding, appendicolith, and abscess. You decide to observe the patient, and she develops more pain, with localized rebound and guarding in the RLQ. SAMPLE