NMS. Casos Clínicos

274

Part II ♦ Specific Disorders

Table 8-6: Modified Hinchey Classification Hinchey Classification Modified Hinchey Classification

Comments 0 Mild clinical diverticulitis Left lower quadrant

pain, elevated white blood cells, fever, no confirmation by imaging or surgery

I Pericolic abscess or phlegmon

I a Confined pericolic inflammation—phlegmon

II Pelvic,

II Pelvic, distant

intra-abdominal, or retroperitoneal abscess

intra-abdominal, or retroperitoneal abscess

III Generalized purulent peritonitis

III Generalized purulent peritonitis

No open communication with bowel lumen Free perforation, open communication with bowel lumen

IV Generalized fecal peritonitis

IV Fecal peritonitis

Fistula colovesical/ colovaginal/coloenteric/ colocutaneous

Obstruction Large and/or small bowel obstruction From Greenfield LJ, Mulholland MW, Lillemoe KD, et al., eds. Greenfield’s Surgery , 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2010.

Case 8.32  History of Left Lower Quadrant Pain with Sensation of Voided Air You treat a 70-year-old for acute diverticulitis, who recovers without complications or need for surgery. A subsequent colonoscopy shows an area of sigmoid diverticula with scarring and a mild stricture of the involved area. Biopsies are negative for tumor. The patient does well at home but returns several months later with a sensation of voided air when urinating. Q: What is the appropriate diagnosis and management? A: Pneumaturia is present. Diverticulitis can form a fistula with most lower abdominal organs with an epithelial lining (Fig. 8-36). In this case, it has formed a fistula with the bladder. This complicates the surgery; it is necessary to separate the diseased segment of bowel from the bladder. Otherwise, the procedure is unchanged. The most common etiology of a colo-vesical fistula is diverticulitis. SAMPLE