Diverticulitis pathology conference 01-29-08 lutheran hospital
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Clinical Pathology/Radiology Conference
Advocate Lutheran General Hospital
Diverticulitis
Sathish Babu MD
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
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
10/20/0710/20/07
10/20/0710/20/07
06/27/0506/27/05
Comparison to CT Scan done in 2005
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
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
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
Initial LABS
14.0 142 106 11
11.2 261 3.7 24 1.4
42.0
132
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
Hospital Course• Initial Leucocytosis which settled, Uneventful
otherwise• Discharged on POD # 6 31st Dec 2007• CT Scan Abdomen- 31st Dec 2007
• F/U- doing well
12/31/0712/31/07
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
SummaryPyogenic 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
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