NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Symptoms suggestive of diverticulitis

Moderate-severe LLQ pain Moderate-severe focal tenderness LLQ +/– fever +/– leukocytosis

Geneneralized abdominal pain, generalized peritoneal

Mild LLQ pain Mild tenderness LLQ +/– fever

Abdominal x-ray

signs Fever Leukocytosis

+/– tachycardia +/– hypotension

No free air

free air

CT abdomen (IV, oral, and rectal contrast)

No imaging study

Free air, extracolonic contrast (open communication to bowel)

Abscess distant pelvis, extrapelvic, retroperitoneal

Pericolic phlegmon or abscess

Colon thickening, pericolic fat stranding, diverticulosis

Modified Hinchey 0

Oral antibiotics, bowel rest

Modified Hinchey Ia

Modified Hinchey Ib

Modified Hinchey II

Resuscitate, OR

Abscess ≤ 2 cm

Abscess > 2 cm

Antibiotics, bowel rest, consider admission

Symptoms resolve

Symptoms worsen

Purulent peritonitis

Fecal peritonitis

Antibiotics, bowel rest, admission

Percutaneous drainage,

Percutaneous drainage,

antibiotics, bowel rest, admission

antibiotics, bowel rest, admission

Modified Hinchey III

Modified Hinchey IV

Resect, consider primary anastomosis

Resect, consider staged procedure

Confirmatory study

Symptoms resolve

Symptoms resolve

Symptoms worsen

Symptoms worsen

Symptoms worsen

Admit Repeat CT

Percutaneous drainage

Confirmatory study; elective, single-stage resection

Repeat CT Consider OR

Figure 8-35: Treatment algorithm for diverticulitis. (From Greenfield LJ, Mulholland MW, Lillemoe KD, et al., eds. Greenfield’s Surgery , 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2010.)

LOWER GASTROINTESTINAL BLEEDING Case 8.33 Massive Lower Gastrointestinal Bleeding A 70-year-old who has been in good health presents to the emergency department with a 4-hour history of large amounts of bright red blood per rectum. A brief his- tory is otherwise negative. On physical examination, the heart rate is found to be 115 beats per minute with a BP of 105/70 mm Hg. The patient appears tired but alert. The conjunctiva appears pale, and the mucous membranes are dry. Heart and lungs are normal except for a resting tachycardia. The abdomen is soft and nontender, and bright red blood per rectum is evident. There is no peripheral edema and weak but present pulses. Neurologically, the patient is intact. SAMPLE