Surgery Case Presentation By: Jennifer Distinti PA-S Presented to: Prof. Acevedo

Chief Complaint: n “ I have been bleeding heavy from below for about 5 days”.

History of Present Illness: n A 73 year old female with a PMH of HTN, diverticulosis, and colon polyps presented to the SBH ER on 10/20/00 at 10:00 p.m.with a c/o of painless rectal bleeding starting 5 days ago, on and off. Patient stated that her clothes were soaked with blood. She admitted to noticing bright red blood in her stool.

Continued... n h/o dizziness, lethargy, and lightheadedness n No h/o abdominal pain n No nausea or vomiting n No h/o SOB, CP, palpitations

Past Medical History: n HTN n Diverticulosis- no surgical Tx. n Polyps, bleeding- received blood transfusion. n No PSH

Other Information: Allergies: n None Family History: n None Medications: n Not known at this time Social History: n Non smoker n No alcohol use n No drug use

Physical Exam in ER: Vitals: n BP: 121/60 n Pulse: 65 n RR: 18 n Temp: 97 General: n AOx3 NAD Skin: n Clear/no rashes HEENT: n No abn. findings Thyroid: n Not enlarged on palpation Lungs: n CTABL no w/r/r Cardiac: n S 1 S 2 r/r/r

Physical Exam Continued: Abdomen: n Soft on palpation n No masses n No organomegaly n + BS on ascultation Rectal: n Melena n Hematachezia Extremities: n No edema/calf pain

Laboratory Results in ER: n H&H: 6.7/19.1 n PT: 11.8 n INR: 0.99 n PTT: 22.8 n Lipase: 121 n Amylase: 81 n Sodium: 139 n Potassium: 4.2 n Chloride: 105 n Bicarbonate: 22 n BUN: 33 n Creatinine: 1.1 n Glucose: 170

Assessment & Plan: n R/O diverticulosis n R/O polyps n NPO n Monitor vitals n IVF D5% NS 50 cc/hr n PRBC n Tagament 300mg IV q 8 hrs. n Monitor labs. (H&H) n Consult GI: sigmoidoscopy/colonoscopy

Anatomy of the Colon:

Anatomy of The Colon: n The colon averages 180cm –Ascending: 8 inches –Descending: 12 inches –Transverse: 18 inches –Sigmoid: 18 inches –The cecum is the first portion of the large bowel and it joins to the small bowel.

Parts of the Right & Left Colon as Well as there Blood Supply: n Right Colon: --->Superior Mesenteric Artery –Cecum –Ascending--->Rt. Colonic Artery –Hepatic Flexure--->Middle Colonic Artery –Proximal Transverse Colon--->Middle Colonic Artery n Left Colon: --->Inferior Mesenteric Artery –Distal Transverse Colon--->Lt. Colonic Artery –Splenic Flexure –Descending Colon--->Lt. Colonic Artery –Sigmoid Colon--->Sigmoid Artery –Rectosigmoid

Lower Endoscopy Report: n Indication for procedure: Hematochezia n Level of insertion: up to cecum; colon 180cm. n Findings: diverticulosis from the proximal descending to proximal transverse colon. Full diverticulosis in ascending colon with blood clots. But no active bleeding. Internal hemorrhoids found as well as colonic polyps in distal ascending colon.

Continued... n Impression & Dx: Diverticulosis from the splenic flexure to proximal transverse with blood clots but no active bleeding. Internal hemorrhoids found as well. n Recommendation: 1. Surgery on 10/24/00 for subtotal colectomy. 2. Monitor CBC 3. Post Op - high fiber/lactose free diet.

Surgical Procedure Used: (However anastamosis was of the ileum not the colon to the rectum)

Surgical Procedure Used:

n The procedure is done under general anesthesia. n An incision is made in the abdomen. The incision is carried through the wall of the abdomen to expose the bowel. n The diseased portion of the colon is identified and that portion of the colon and it’s blood supply is divided and removed. n A stapler placed across the colon seals the colon on each side of the stapler and then cuts the colon between the stables. Then the small bowel is joined (anastamosis) to the rectum using a specific instrument. After the surgery the abdominal wound was closed with staples.

Postoperative Status: n Postop this patient did very well. She had no physical complaints of abdominal pain of tenderness on exam. She had + BS and she was having loose stools which was expected. Her vitals remained stable and she was in good spirit. The rest of her physical exam was normal. The incision had no signs of erythema, edema, infection or discharge and we removed the staples on post op day #8. She was put on a low residue/lactose free diet. PT was call to start the patient ambulating and depending on her H&H and whether or not blood was found in her stool, she would be discharged on 11/03/00, which she was.

Diverticulosis: n It is a condition that is common in Western society. n It increases with age & it is present in approx. 75% of Americans over age 80. n It is associated with diverticula, which are protrusions of the innermost lining of the colon through the muscular outer layer of the colon wall. n The diverticula can become inflamed, a condition called diverticulitis which can cause perforation of a bowel abscess, bleeding, obstruction of the bowel or fistulae of the colon.

Pathophysiology: n A decrease in fiber in the diet is associated with a high incidence of diverticulosis in Western population. –One thought is that when circular muscular contractions occur in pts. with small amounts of stool in the colon, the colon lumen becomes occluded. –When two contractions occur close to one another the lumen of the intervening segment of the colon is isolated from the rest of the colon and high pressure is generated in that segment. –Increased pressure results in the formation of diverticula by placing increased tension on the colon wall.

Symptoms and Complications of Diverticulosis: n Bleeding (usually right sided)may be massive n Diverticulitis(LLQ pain which is cramping or steady, change in bowel habits, fever, chills, anorexia, nausea, vomiting and dysuria) n Asymptomatic (80%) usually diagnosed incidentally on endoscopy or BE.

Diagnosis of Diverticulosis: n Usually incidentally during a barium x-ray. n Evaluation of older patients with recent onset of bowel disturbances should include: –Occult blood –CBC –Sigmoidoscopy –Barium enema or colonoscopy

Differential Diagnosis of Lower GI Hemorrhage: n Colonic diverticular Dz. n Colonic vascular ectasias n Small intestinal diverticular Dz. (Meckels diverticulum, pseudodiverticula). n Inflammatory bowel Dz. (Chronic Ulcerative Colitis, Crohn’s Dz.). n Colonic Neplasms n Small intestinal neoplasms n Angiodysplasia n Aorticenteric fistulae n Colitis (infection, ischemia, radiation induced). n Internal Hemorrhoidal Dz.

Treatments of Diverticulosis: n Treatment depends on the severity and location of the diverticulosis, as well as the status of the patient. n A high fiber diet is recommended n Broad spectrum antibiotics if asymptomatic n Examples of surgical procedures used are: –colostomy –iliostomy – right or left hemicolectomy –subtotal colectomy with anastamosis

Continued: n The indications to operate on a patient with diverticulosis are: –complications of diverticulitis (abscess, fistula, obstruction, stricture). –Recurrent episodes of diverticulitis –Hemorrhage –Suspected carcinoma –Prolonged symptoms –ischemic colon –toxic megacolon

Complications of Colon Surgery: n Postoperative bleeding n Dehiscence or breakdown of the anastomosis n Recurrence of a tumor n Wound infection n Urinary or respiratory infection n DVT with or without PE n Urinary retention n Adhesions with bowel obstruction n Obstruction at the anastomosis site

THE END