NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Case 8.31  Left Lower Quadrant Pain in a Deteriorating Patient You admit a 75-year-old with LLQ pain, fever, and nausea who has a presumptive diagnosis of acute diverticulitis. An obstructive series is unremarkable, and the WBC count is 15,000 cells/mm 3 . Therapy with antibiotics, bowel rest, and IV fluids begins, with a plan to follow the patient clinically. Despite this treatment, the patient deterio- rates, with continued pain, increasing fever, and rising WBC count.

Q: What is the suspected problem? A: The patient has a free perforation or an intra-abdominal abscess.

Q: What is the appropriate evaluation? A: CT may demonstrate abscess, perforation, or other complications of the acute inflamma- tory process. In addition, it may also reveal the presence of diverticula.

The CT scan demonstrates a loculated fluid collection in the pericolic gutter.

Q: What management is appropriate? A: A loculated fluid collection with a CT-guided needle insertion of a catheter into the collec- tion is warranted. This method allows the fluid to be sampled and drained. The treatment algorithm for diverticulitis is complex and based on the modified Hinchey classification (Table 8-6 and Fig. 8-35). The drained fluid is purulent and contains gram-negative bacilli. With a catheter left in the collection, the patient improves. Q: What is the appropriate management? A: It is necessary to leave the drainage catheter in place until the cavity shrinks to a small size and the drainage stops. If the patient tolerates food and remains afebrile, the patient can be discharged. However, many patients with a persistent ileus or functional obstruction from the edema do not tolerate food and require TPN for a period of time. Surgical resection may be indicated after this episode of complicated diverticulitis. Q: How would the proposed management change if the patient did not improve with catheter drainage? A: If the patient worsens clinically, a Hartmann procedure with resection of the colon and inflammatory mass, with a colostomy, is warranted (see Fig. 8-8). If possible and safe, colon resection for diver- ticulitis should be done electively by treating the complications of diverticulitis with anti- biotics, gut rest, and percutaneous drainage of abscesses to minimize complications of surgery. SAMPLE Digging Deep