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Diverticulitis pathology conference 01-29-08 lutheran hospital
- 1. Clinical Pathology/Radiology Conference Advocate Lutheran General Hospital Diverticulitis Sathish Babu MD
- 2. Presentation • 53 Y Caucasian male presented for elective LAR • DOA- 12/23/07 • Background- H/O IBS, depression, anxiety, N&V since 2 years, diagnosed as having Diverticulosis, recurrent N&V- decreased GB EF- Pancreatitis- ERCP- Sphincterotomy- Cholecystectomy • Persistent recurrent N&V, many ER visits, coffee ground emesis, no malena or BRBPR • Endoscopies- EGD/Colonoscopy-negative except Diverticulosis of Sigmoid, CT Scan Abd/Head- negative
- 3. History • Diagnosis- Cyclic Vomiting Syndrome- specific therapies not available • May 2007- Diagnosed to have Mallory Weiss tear due to his vomiting about 20 times • Oct 19th 2007- Diffuse Myalgia, Backache, fever 101.2 with Vomiting. ER- increased WCC 20, no abdominal pain, hematuria or dysuria, no rigors • CT Scan- Oct 20th 2007- • Irrgular low-desity mass 6.2x5.1-not a simple cyst- necrotic mass, Diverticulitis
- 6. 06/27/0506/27/05 Comparison to CT Scan done in 2005
- 7. 10/23/0710/23/07 Oct 22nd 2007- CT guided Drainage- 20ml purulent fluid aspirated , 8FR pigtail catheter left in situ •ID on board- Zosyn & Flagyl started • Post procedure CT- abscess reduced to 3.2cms Diverticulitis improved
- 8. History • Abscess- GPC and GPB, Streptococci, Blood Cx- no growth • D/C on Home ABX, liver drain came out eventually • f/u 11/21/07- planned for Interval Colonoscopy • Colonoscopy- Dec 13th 2008- • Inflammation in Sigmoid Colon- resolving Diverticulitis, no diverticula noted • Normal Colonoscopy otherwise • Elective Admission- 23rd 2007
- 9. H & P • VITAL SIGNS: 114/72 mmHg, 97 F, RR 20, PR 53, 100% Sao2 • The patient in no acute distress • HEENT: EOMI, PERLA • CHEST: CTA • CVS- RRR • P/A- Soft NT/ND • Rest of the exam- normal
- 10. Initial LABS 14.0 142 106 11 11.2 261 3.7 24 1.4 42.0 132
- 11. Surgery • 24th Dec 2008- • Laparoscopic LAR, Hand Assisted • Pathology- Colon Recto sigmoid resection • -Diverticulosis and Diverticulitis, Severe • -Peri-intestinal lymph node with reactive hyperplasia • -Remaining colonic mucosa with no pathological change
- 12. Hospital Course • Initial Leucocytosis which settled, Uneventful otherwise • Discharged on POD # 6 31st Dec 2007 • CT Scan Abdomen- 31st Dec 2007
- 13. 12/31/0712/31/07
- 14. Literature Med Arh. 2007 ;61 (2):117-8 17629149 [Management of liver abscess formed after asymptomatic sigmoid diverticulitis] Predrag Jovanović , Enver Zerem , Muharem Zildzić Liver Abscess Secondary to Sigmoid Diverticulitis A Case Report- 2005 Department of Colon-Rectal Surgery Department of Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan, R.O.C Pyogenic liver abscess secondary to asymptomatic sigmoid diverticulitis. M K Wallack, A S Brown, R Austrian, and W T Fitts Dept of Surgery , University of Pennsylvania, Philadelphia- 1976
- 15. Summary Pyogenic Liver Abscess- RUQ pain (50%), Fever, leucocytosis, Increased ALP and Bilirubin if biliary tract is involved Most common cause- Biliary tract Disease-30%, Pyelephlebitis (from portal vein), Hematogenous spread, Direct extension of intra abdominal infection Polymicrobial PCD/PNA & IV Abx has completely replaced Surgery but Surgery is an important consideration for those who fail PCD/PNA Intestinal Evaluation to search for cause