NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

due to adhesions, an internal hernia, or an obstructed anastomosis has occurred . These developments may require CT or a small bowel series to identify the problem, depending on the postoperative day and condition of the patient. The patient may require reoperation for anastomotic leakage, obstruction with ischemia, or potential ischemia. Case Variation 8.24.2. A reddened, fluctuant area develops at the inferior aspect of the wound ◆ ◆ This suggests a wound infection . Management usually involves opening the involved por- tion of the wound down to the fascia, with inspection of the fascia to determine whether it is intact. Local wound care is sufficient for most uncomplicated wound infections.

Case Variation 8.24.3. Feculent material drains from the inferior aspect of the wound ◆ ◆ This suggests a wound infection caused by an anastomotic leak that has spontaneously drained (necessitated) to the skin. NPO feeding and IV fluids are usually sufficient for most colon fistulas, the majority of which will close with this therapy . A CT scan of the abdomen determines whether there is an undrained collection , which needs draining ei- ther operatively or percutaneously, which is preferable. If any doubt about the patency of the anastomosis exists, surgical exploration or a gentle Gastrografin enema or colonoscopy may be appropriate, although most surgeons would be very hesitant to do this early in the course of a fistula with a fresh anastomosis. A fistula with a distal obstruction due to a nonpatent anastomosis (i.e., obstructed) will not close. It requires operative revision and an ileostomy proximally to divert the fecal stream. Case Variation 8.24.4. The patient returns to the hospital 10 days postoperatively with a temperature of 104°F and abdominal pain in the RLQ ◆ ◆ This suggests an abscess , most likely in the right paracolic gutter or pelvis. Most commonly, diagnosis is by CT, and management is by percutaneous drainage. Concern regarding anas- tomotic leakage is also present, and the previously discussed management is appropriate (see Case Variation 8.24.3). Case Variation 8.24.5. The patient returns in 6 months with crampy abdominal pain, decreased stool caliber, and constipation ◆ ◆ These symptoms could represent anastomotic recurrence of the cancer as well as a stric- ture at the anastomosis. Strictures usually result from excessive scar formation due to inadequate blood supply to the anastomosed segments. It is also possible that a second ob- structing cancer, which could have been missed at initial surgery, is causing the symptoms. Colonoscopy usually establishes the diagnosis. A 55-year-old presents with constipation, rectal bleeding, and a feeling of fatigue. On examination, you find a constricting hard lesion 4 cm from the anal verge. Biopsy indicates adenocarcinoma of the rectum. SAMPLE Case 8.25  Heme-Positive Stool in Patient with Rectal Adenocarcinoma