This document discusses three cases of acute abdominal conditions seen by a surgical gastroenterologist. Case 1 involves a 55-year-old male with left lower quadrant pain and fever diagnosed with diverticulitis based on CT findings. The patient underwent left hemicolectomy with sigmoid resection and diverting loop ileostomy. Case 2 describes a 53-year-old male with abdominal pain found to have an acute SMA thrombosis on CT angiography. The patient was treated conservatively with heparin and antibiotics. Case 3 involves a 65-year-old cirrhotic male with SMV thrombosis found on CECT. The patient deteriorated clinically despite conservative management and required small bowel resection during

1. GI Update
Diverticular Disease
Dr Dhaval Mangukiya
Surgical Gastroenterologist

2. Case 1
• 55 year old male
• No Medical co morbidities
• Pain in left iliac fossa since 6 days
• Fever since 5 days
• Chronic constipation since more than 2 yr
• O/E:
– Tachycardia (96/min)
– Other parameters Normal
– P/A: Moderately distended abdomen, severe tenderness
in LIF

3. • USG Abdomen:
– Grade 1 fatty liver
– Gall stones
– Focal edematous thickening of mesentery in LIF with
edematous adjacent descending colon and ileal loop
– R/O: Diverticular ds/Non specific inflammation
• TC: 18 200 Rest normal
• What next?

4. Diverticular disease consists of:
o Diverticulosis: the presence of diverticula within the
colon
o Diverticulitis: inflammation of a diverticulum
o Diverticular bleeding
Types of diverticular disease:
• Simple (75%), with no complications
• Complicated (25%), with abscesses, fistula,
obstruction, peritonitis, and sepsis

5. Choice of
investigation
• CT scan
• Dye study
• Colonoscopy
• X-ray Abdomen
(sensitivity69-98%,specificity75-100%)
(sensitivity62-94% falsenegative2-15%)
(C/I in acute setting)

6. Differential diagnosis:
o Carcinoma of the bowel
o Pyelonephritis
o Inflammatory bowel disease
o Appendicitis
o Ischemic colitis
o Irritable bowel syndrome
o Pelvic inflammatory disease

7. • CT scan protocol
– Plain
– IV contrast
– Rectal contrast
– Oral contrast

8. • Points to look in CT
– Diagnosis
– Classify the complicated diverticulitis
– Plan the management

9. CT findings
• Inflamed pericolic fat
• Diverticula
• Thickened bowel wall
• Pericolic abscess
• Peritonitis
• Fistula
• Colonic obstruction
• Intramural sinus tracts

10. • CT scan IV and Rectal contrast
– Thickened left colon with mesenteric fat stranding
– Large collection retrocolic and mesocolon
– Mild free fluid intraperitoneum
– Small bowel loop adhered in left iliac region with wall
thickening
– leak of contrast in abscess cavity
– No e/o fistulous connection
• Further plan of action…..

11. • Options
– Conserve and antibiotics
– CT/USG guided pigtail
– Laparoscopy and Lavage
– Emmergency exploration

12. Indications for elective surgery
• Two or more episodes of diverticulitis severe
enough to cause hospitalization
• Any episode of diverticulitis associated with
contrast leakage, obstructive symptoms, or an
inability to differentiate between diverticulitis and
cancer

13. Exploration: findings
• Pyoperitoneum appx 50 cc
• Sigmoid and descending up to splenic flexure was
involved
• Terminal ileum densely adhered with sigmoid
• Pus cavity left to sigmoid appx 300 cc
• Multiple sigmoid perforated diverticulitis (pus)
• Inflamed terminal ileum without any fistulous
connection

14. Surgical modality?
• Hartmann procedure (Left colectomy with end
stoma)
• Resection, proximal bowel wash, colorectal
anastomosis with diverting ileostomy
• Resection, bowel was through appendix, colorectal
anastomosis, with ileostomy
• Primary resection and colorectal anastomosis
• With cholecystectomy?

15. In this patient
• Resection (Left extended Hemicolectomy with
sigmoid)
• Proximal colon wash with saline
• Colorectal anastomsis
• Diverting loop ileostomy
• Expected post op events and management?

16. Primary resection
• Associated with a shorter hospital stay
• Associated with reduced morbidity than
with colostomy alone and drainage
• Associated with a lower mortality than with
colostomy alone versus resection (26% vs.
7%)
• Associated with a survival advantage
 Rodkey GV, Welch CE. Changing patterns in the surgical treatment of diverticular disease. Ann Surg
1984;200:466–78 (PMID: 6333217).
 Aguste L, Barrero E, Wise L. Surgical management of perforated colonic diverticulitis. Arch Surg
1985;120:450–2 (PMID: 3985790).
 Finlay IG, Carter DC. A comparison of emergency resection and staged management in perforated
diverticular disease. Dis Colon Rectum 1987;30:929–33 (PMID: 3691263).
 Nagorney DM, Adson MA, Pemberton JH. Sigmoid diverticulitis with perforation and generalized
peritonitis. Dis Colon Rectum 1985;28:71–5.
 Krukowski ZH, Matheson NA. Emergency surgery for diverticular disease complicated by generalized
and faecal peritonitis: a review. Br J Surg 1984;71:921–7 (PMID: 6388723).

17. Annals of Surgery; Volume 256, Number 5, November 2012
Conclusion
• Primary outcome did not differ
• Strong evidence favoring PA with protective ileostomy
over HP in the treatment of acute left-sided colonic
perforation with generalized peritonitis
• The benefits directly relate to the stoma reversal
operation, which is more likely to occur and safer in PA
• Further investigations are required to identify a group of
patients, which may potentially not require a diverting
ileostomy

18. Case 2
• 53 year old male
• No IHD/DM/HT…
• Acute onset abdominal pain
• Distension
• No fever
• Vitals-stable
• Abdomen-severe tenderness, distended

19. • What are the differentials?
• When to suspect mesenteric ischaemia?
• Blood investigations to support?

20. • Hb-7.8
• TC-10,800
• S.creat-1.3
• ABG-Acidosis
• Lactate(ABG)-3 (Increased)
• USG: asymmetric bowel wall thickening, minimal
free fluid
• What is next step??

21. CT Scan

22. CT Scan

23. CT Scan

24. CT Scan

25. CT Scan

26. CT Scan

27. CT Scan

28. CT Scan

29. CT Scan

30. CT Scan

31. • Findings of CT Scan?
• Interpretation?
• Helpful in deciding line of management?
• Acute SMA thrombus at origin
• Thickened proximal bowel loops
• No obvious gangrene

32. Opinion
• Medical
• Surgery??

33. Management
• Conservative
• ICU admission with parameter monitoring
• Fluid resuscitation
• Heparin infusion
• aPTT monitoring
• Broad spectrum Antibiotics

34. • Strategy for conservative management?
• When to repeat imaging or only clinical judge?
• Protocol??

35. Repeat CT Scan Day 3

36. Repeat CT Scan

37. Repeat CT Scan

38. Repeat CT Scan

39. Repeat CT Scan

40. Repeat CT Scan

41. Repeat CT Scan

42. Repeat CT Scan

43. Repeat CT Scan

44. Repeat CT Scan

45. Repeat CT Scan

46. Repeat CT Scan

47. Repeat CT Scan

48. Repeat CT Scan

49. Repeat CT Scan

50. • Alarming signs/findings on follow up imaging?
• What are the instructions to radiologist while
prescribing the first and repeat scans-
Oral/IV/triphasic/negetive contrast….?
• Blood investigations- interpretation-
ABG/Lactate/TC as marker of gangrene?

51. In this patient
• Condition- improving
• Diet started
• Oral – Clopidogril/Aspirin and Warfarin

52. • Would you encourage oral diet as soon as possible
or keep NBM
• Medical management of arterial thrombosis and
etiological work up in this pt.
• Role of diagnostic Lap in AMI when in dilemma

53. After Discarge
• On follow up (3 months)
• Post prandial pain after 2 hrs of meals
• Black colored stool
• Mild distension
• Occ. vomiting

54. • What do you suspect and further investigation?
• Admit?
• Investigation?
• Imaging?

55. Blood Investigation
• CBC – Normal
• INR – 3.2 (On warfarin)
• RFT – Normal
• LFT – Normal
• Is it due to anticoagulants or ischaemia?

56. CT Scan

57. Options
• Diagnostic Laparoscopy – Role and indications?
• Formal Angiography-Feasibility?
• Endoscopy?

58. Case 3
• 65 year old male
• CLD/DM/HT
• H/o variceal banding – 2 times
• Severe pain in abdomen & distension
• USG- Normal
• X-ray abdomen - Normal
• TC- Normal
• Platelets- 70,000
• Liver/renal function- preserved
• CHILD POUGH Type A

59. CECT
• SMV thrombosis
• PV – Normal
• Thickened bowel wall without any obvious s/o
gangrene
• Cirrhotic liver
• What else you would like to know?

60. • Hemodynamic – Stable
• UO – maintained
• ABG – mild acidosis
• Options…
– Surgery
– Conservative

61. Management
• Conservative
• Heparin infusion
• Antibiotics
• ICU monitoring
• ABG 8 hourly
• Signs to look for?

62. • After 12 hrs of admission
– Tachycardia
– Hypotension- ionotrpes started
– Low UO
– ABG – acidosis
• Next action? – Repeat imaging/surgery

63. On exploration
• Gangrene involving distal jejunum and proximal
ileum appx 25-30 cm
• Resection done
• Selection?
– Primary anastomosis
– Stoma

64. In this patient
• Anastomosis without stoma done
• Post op heparin continued

65. • How you will monitor this pt?
• Any other etiological work up?
• Special consideration and precautions in the setting
of CLD?
• Would you like to repeat imaging or second look
exploration or wait? – role and any evidence to
support you decision.

67. THANK YOU