Disorders of Small Disorders of Small and Large Boweland Large BowelJay GreenJay GreenOctober 26, 2006October 26, 2006

Case 1Case 1 54 y.o. F, abdominal pain54 y.o. F, abdominal pain Started 2 days ago, shortly after Big MacStarted 2 days ago, shortly after Big Mac Hurts all over, comes and goes, crampyHurts all over, comes and goes, crampy +D yesterday, bloated, +N today, +D yesterday, bloated, +N today, ø Vø V PMH: DMII, HTN, TAH/BSO (’04)PMH: DMII, HTN, TAH/BSO (’04) Ideas?Ideas?

DDx - ApproachDDx - Approach Think anatomyThink anatomy

Intraperitonaeal, retroperitoneal, otherIntraperitonaeal, retroperitoneal, other Think VITAMIN D, VINDICATED, whatever…Think VITAMIN D, VINDICATED, whatever… VascularVascular

Ischemic gut, MI, AAAIschemic gut, MI, AAA InfectionInfection

Gastro, PUD, psoas abscessGastro, PUD, psoas abscess NeoplasticNeoplastic

IntussusceptionIntussusception InflammatoryInflammatory

Diverticulitis, Cholecystitis, Pancreatitis, AppendicitisDiverticulitis, Cholecystitis, Pancreatitis, Appendicitis TraumaticTraumatic

ObstructionObstruction PregnancyPregnancy

Small Bowel ObstructionSmall Bowel Obstruction Top 3 causes?Top 3 causes?

HerniaHernia AdhesionsAdhesions CACA

Most likely to cause strangulation?Most likely to cause strangulation? Hernia – often closed loopHernia – often closed loop

Others to think about?Others to think about? Gallstone ileus, volvulus, intussusception, Gallstone ileus, volvulus, intussusception,

abscess, hematoma, foreign bodyabscess, hematoma, foreign body

More than half of SBO recurrMore than half of SBO recurr TrueTrue FalseFalse

Bathing in tomato juice removes the smell Bathing in tomato juice removes the smell of a skunkof a skunk

TrueTrue FalseFalse

SBO – Quick factsSBO – Quick facts 20% of acute abdo admissions20% of acute abdo admissions Mortality <5% (30% with strangulation, Mortality <5% (30% with strangulation,

60% in 1900)60% in 1900) >50% recur>50% recur

H&PH&P Recurrent abdo pain, crampy, <>Recurrent abdo pain, crampy, <> Worry if pain becomes constant severeWorry if pain becomes constant severe Vomiting, distension, constipationVomiting, distension, constipation Prev surgeryPrev surgery Vitals: normal, tachy, hypoTN, feverVitals: normal, tachy, hypoTN, fever Distention, Distention, ∆∆BS (BS (↑ pitch), tympany↑ pitch), tympany ±scars/hernia, ±tender mass±scars/hernia, ±tender massBohner H, et al:  Simple data from history and physical examination help to exclude bowel obstruction and to avoid radiographic studies in patients with acute abdominal pain.   Eur J Surg  1998; 164:777

Vomiting, distension, constipationVomiting, distension, constipation Prev surgeryPrev surgery

∆ ∆BSBS

Review of the basicsReview of the basics

Types?Types? Mechanical & functionalMechanical & functional Simple & closed loop (Simple & closed loop (±strangulation)±strangulation)

Common causes of ileus?Common causes of ileus? Trauma, infection, sx, meds, metabolic, Trauma, infection, sx, meds, metabolic,

renal colicrenal colic

Physicians reliably can distinguish bowel Physicians reliably can distinguish bowel strangulation from simple obstructionstrangulation from simple obstruction

TrueTrue FalseFalse

Cracking knuckles leads to arthritisCracking knuckles leads to arthritis TrueTrue FalseFalse

Simple vs Strangulated - Simple vs Strangulated - How good are we?How good are we?

Confident diagnosis of “non-strangulating Confident diagnosis of “non-strangulating obstruction” wrong 31% of the time.obstruction” wrong 31% of the time.

No parameter is sensitive, specific, or No parameter is sensitive, specific, or predictive for strangulationpredictive for strangulation

Not very good!Not very good!

Sarr et al. Preoperative recognition of intestinal strangulation obstruction: Prospective evaluation of diagnostic capability. Am J Surg 145:176-182, 1983.

PathophysiologyPathophysiology

Mechanical SBO Mechanical SBO → → prox dilationprox dilation→ ↑ → ↑ local peristalsis local peristalsis → ↑ → ↑ secretory activitysecretory activity→ ↓ → ↓ reabsorption fluid/lytesreabsorption fluid/lytes→ → capillary/lymphatic obstruction capillary/lymphatic obstruction → → edema edema → → perforation or strangulationperforation or strangulation

InvestigationsInvestigations Labs:Labs:

↑↑WBC, WBC, ±±↑CPK, ↑CPK, ±±↑lactate↑lactate

Imaging:Imaging: 3 views (60% +SBO, 25% suggestive)3 views (60% +SBO, 25% suggestive)

Five places to look for air?Five places to look for air? How many A/F levels?How many A/F levels? Dilated?Dilated?

CT Scan?CT Scan? Not required for diagnosisNot required for diagnosis Can help define site/causeCan help define site/cause

Other imaging?Other imaging? Small bowel series, U/SSmall bowel series, U/S

What about U/S?What about U/S?

SNSN SPSP EtiologyEtiology

Plain filmsPlain films 77%77% 50%50% 7%7%

U/SU/S 83%83% 100%100% 23%23%

CTCT 93%93% 100%100% 87%87%

½ of complete SBO resolve ½ of complete SBO resolve spontaneouslyspontaneously

TrueTrue FalseFalse

Eating 3 poppy seed bagels may result in Eating 3 poppy seed bagels may result in positive urine drug screen for opiatespositive urine drug screen for opiates

TrueTrue FalseFalse

ManagementManagement Fluid resuscitationFluid resuscitation DecompressionDecompression

NG tubeNG tube ?Antibiotics?Antibiotics Observation vs. surgeryObservation vs. surgery

““never let the sun rise or set on an SBO”never let the sun rise or set on an SBO” 75% of partial/30-50% complete resolve75% of partial/30-50% complete resolve

Take home pointsTake home points You are not good at dx strangulationYou are not good at dx strangulation

AXR - >2 A/F levels, >2.5cm, air x 5AXR - >2 A/F levels, >2.5cm, air x 5

½ of SBO resolve spontaneously½ of SBO resolve spontaneously

Case 2Case 2 28M central/RLQ crampy abdominal 28M central/RLQ crampy abdominal

pain, Npain, N Last BM this am, no fever/chills/VLast BM this am, no fever/chills/V Best guess?Best guess? 28F same hx?28F same hx?

25% signs initially suggestive of appe = gyne25% signs initially suggestive of appe = gyne 84F type II DM same hx?84F type II DM same hx? 4M same hx? 4M same hx?

Case 2Case 2 Vitals – 37.3, 85, 126/85, 18Vitals – 37.3, 85, 126/85, 18 RLQ tenderness, +guardingRLQ tenderness, +guarding

Investigations?Investigations?

Appendicitis – Quick factsAppendicitis – Quick facts 7% lifetime incidence7% lifetime incidence 250 000 cases/yr in the USA 250 000 cases/yr in the USA First appendectomy – 1735First appendectomy – 1735

What the heck is this?What the heck is this?

The AppendixThe Appendix "Its major importance would appear to be "Its major importance would appear to be

financial support of the surgical financial support of the surgical profession." - Alfred Sherwood Romerprofession." - Alfred Sherwood Romer

Leonardo da Vinci (1492)

PathophysiologyPathophysiology ObstructionObstruction ↑ ↑ pressurepressure distensiondistension ischemia + bacteria/PMN invasionischemia + bacteria/PMN invasion swells, irritatesswells, irritates necrosis and rupturenecrosis and rupture

HistoryHistory Three most common symptoms?Three most common symptoms?

abdo pain, anorexia, nauseaabdo pain, anorexia, nausea Rule out based on pain location?Rule out based on pain location?

no, can even have LUQ painno, can even have LUQ pain

Physical examPhysical exam Vitals – 37.3, 85, 126/85, 18Vitals – 37.3, 85, 126/85, 18 Do normal vitals r/o appendicitis?Do normal vitals r/o appendicitis? What if T = 38.1?What if T = 38.1?

Low grade fever in 15% (40% if ruptured)Low grade fever in 15% (40% if ruptured) EponymsEponyms

McBurney’sMcBurney’s, Rovsing’s, Obturator, Psoas, , Rovsing’s, Obturator, Psoas, DunphyDunphy

H&PH&P Three important signs/symptoms?Three important signs/symptoms?

RLQ pain, rigidity, migration of painRLQ pain, rigidity, migration of pain Four to help rule out appendicitis?Four to help rule out appendicitis?

Pain > 48h, similar pain, lack of migration, Pain > 48h, similar pain, lack of migration, lack of lack of ↑↑ pain with movement/cough pain with movement/cough

CMT is uncommon in women with acute CMT is uncommon in women with acute appendicitisappendicitis

TrueTrue FalseFalse

The air expelled in a sneeze can travel The air expelled in a sneeze can travel up to 100mphup to 100mph

TrueTrue FalseFalse

Classic AppendicitisClassic Appendicitis Peri-umbilical pain Peri-umbilical pain RLQ migration RLQ migration N, anorexia, VN, anorexia, V No history of similar pain in pastNo history of similar pain in past Pain < 48hrs at presentationPain < 48hrs at presentation Pain Pain ↑ with movement/cough↑ with movement/cough Low grade feverLow grade fever Rigidity & guardingRigidity & guarding Local RLQ tendernessLocal RLQ tenderness

Serial examsSerial exams Review of 30 years of publicationsReview of 30 years of publications ““active observation” = reassess pt q2-3hactive observation” = reassess pt q2-3h Pain resolved in 1/3 of patients Pain resolved in 1/3 of patients No change in perforation rateNo change in perforation rate Negative appendectomy rate 6%Negative appendectomy rate 6%

vs 20-30% (?lower with CT or U/S)vs 20-30% (?lower with CT or U/S)

Jones PF.  Suspected acute appendicitis: Trends in management over 30 years. Jones PF.  Suspected acute appendicitis: Trends in management over 30 years.   Br J SurgBr J Surg  2001; 88:1570-77.  2001; 88:1570-77.

What labs?What labs? Commonly orderedCommonly ordered

CBC, CBC, ββ-hcg, U/A-hcg, U/A ±LFT’s/lipase, ±CRP±LFT’s/lipase, ±CRP

FindingsFindings ↑ ↑ WBC, U/A – pyuria, microscopic hematuriaWBC, U/A – pyuria, microscopic hematuria

Necessary?Necessary?

ββ-hcg!-hcg!

U/S vs CTU/S vs CT CTCT

SN 94%, SP 95%, LR+ 13.3, LR- 0.09SN 94%, SP 95%, LR+ 13.3, LR- 0.09 + usually visualize appendix, not operator + usually visualize appendix, not operator

dependent, ID other pathologydependent, ID other pathology - radiation- radiation

Contrast?Contrast? Rectal – best but not practicalRectal – best but not practical Oral – delay, ?tolerated, esp. helpful in thin/kidsOral – delay, ?tolerated, esp. helpful in thin/kids IV – not recommendedIV – not recommended

U/S vs CTU/S vs CT U/SU/S

SN 86%, SP 81%, LR+ 5.8, LR- 0.19SN 86%, SP 81%, LR+ 5.8, LR- 0.19 + pregnant, kids, female, thin pts+ pregnant, kids, female, thin pts - obese, strictures, retrocecal, normal- obese, strictures, retrocecal, normal

MRI?MRI? Very sensitive but not availableVery sensitive but not available

?Change Management??Change Management? 2 studies of CT in pts w/ suspected 2 studies of CT in pts w/ suspected

appendicitis comparing Tx plan before & after appendicitis comparing Tx plan before & after access to results of scansaccess to results of scans CT changed disposition in 27 – 59% of ptsCT changed disposition in 27 – 59% of pts Prevented d/c of ~3% pts w/ appendicitisPrevented d/c of ~3% pts w/ appendicitis Prevented negative laparotomy in 3-13%Prevented negative laparotomy in 3-13% Alternate Dx in 11-20%Alternate Dx in 11-20%

Frank et al. Unenhanced helical CT scanning of the abdomen and pelvis Frank et al. Unenhanced helical CT scanning of the abdomen and pelvis changes disposition of patients presenting to the emergency department changes disposition of patients presenting to the emergency department with possible acute appendicitis. J Emerg Med 2002; 23: 1-7with possible acute appendicitis. J Emerg Med 2002; 23: 1-7

Rao et al. Effect of computed tomography of the appendix on treatment Rao et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Eng J Med. 1998; 338: 141-of patients and use of hospital resources. N Eng J Med. 1998; 338: 141-66

Thanks Moritz!

To image or not?To image or not? Imaging based on risk-stratificationImaging based on risk-stratification

Don’t image:Don’t image: Low risk – Low risk – minimal physical findings, hungry, alternative dx, minimal physical findings, hungry, alternative dx,

hx similar pain, sympt > 3 dayshx similar pain, sympt > 3 days First few hours of painFirst few hours of pain

Image Image Intermediate risk – lack classic appendicitis findingIntermediate risk – lack classic appendicitis finding

?Image?Image High risk – classic presentationHigh risk – classic presentation Will go to OR anywayWill go to OR anyway

Wake the surgeon?Wake the surgeon? Time from onset of symptoms to rupture?Time from onset of symptoms to rupture?

24-36 hours24-36 hours Average time to seek medical careAverage time to seek medical care

17 hours17 hours Complication rate Complication rate

3% vs 12% with rupture3% vs 12% with rupture MortalityMortality

<0.1% vs 3-4% with rupture<0.1% vs 3-4% with rupture

Take home pointsTake home points Normal vitals do not rule out appendicitisNormal vitals do not rule out appendicitis

Think about U/S over CT in skinny/kidsThink about U/S over CT in skinny/kids

Image pts with equivocal presentationImage pts with equivocal presentation

Single most important lab test Single most important lab test ββ-hcg-hcg

Mesenteric adenitis?Mesenteric adenitis? Most common associated conditionMost common associated condition

5-10% admissions for appendicitis5-10% admissions for appendicitis ?More common than appendicitis?More common than appendicitis Mostly childrenMostly children Non-specific infl. of mesenteric LNNon-specific infl. of mesenteric LN

Can follow viral illnessCan follow viral illness Yersinia species (Y. enterocolitica)Yersinia species (Y. enterocolitica)

Mesenteric adenitis?Mesenteric adenitis?

O/E:O/E: ±±Mild feverMild fever Diffuse tenderness, RLQ, no peritonitisDiffuse tenderness, RLQ, no peritonitis 20% other lymphadenopathy20% other lymphadenopathy

Ix: Ix: ±↑WBC ±↑WBC U/S or CT may be helpfulU/S or CT may be helpful

Tx: Tx: none, self-limitednone, self-limited

Case 3Case 3 65M65M Suprapubic and LLQ pain x days, similar bouts Suprapubic and LLQ pain x days, similar bouts

of pain in pastof pain in past Anorexia, nauseaAnorexia, nausea O/E: Vitals normal, LLQ tender, no peritoneal O/E: Vitals normal, LLQ tender, no peritoneal

signs, ?distendedsigns, ?distended

#1 in DDx?#1 in DDx? Initial investigations?Initial investigations?

Diverticular disease factsDiverticular disease facts 10% > 45yrs, 80% > 80yrs10% > 45yrs, 80% > 80yrs ?Dietary deficiency in fibre?Dietary deficiency in fibre 85% L-sided (opposite in Japan)85% L-sided (opposite in Japan)

DefinitionsDefinitions

Diverticulosis

Asymptomatic(70%)

Diverticular bleeding(10%)

Diverticulitis(20%)

Uncomplicated(75%)

Complicated(25%)

DefinitionsDefinitions

Diverticulosis

Asymptomatic(70%)

Diverticular bleeding(10%)

Diverticulitis(20%)

Uncomplicated(75%)

Complicated(25%)

Anatomy/PathogenesisAnatomy/Pathogenesis Vasa recta penetrate colonic wallVasa recta penetrate colonic wall Forms weak pointsForms weak points

Small (low fibre) stool Small (low fibre) stool ↑ pressure ↑ pressure herniation of mucosa at vasa rectaherniation of mucosa at vasa recta

DiverticulosisDiverticulosis

Clinical featuresClinical features Usually nilUsually nil Can present like IBSCan present like IBS

Abdo pain/crampingAbdo pain/cramping BloatingBloating Constipation/diarrheaConstipation/diarrhea

ManagementManagement If necessaryIf necessary

AnalgesiaAnalgesia Anti-spasmodicsAnti-spasmodics

Modify natural history of diseaseModify natural history of disease High-fibre dietHigh-fibre diet ±stool softeners±stool softeners

Case 3bCase 3b 65M65M HematocheziaHematochezia No painNo pain O/E: Vitals normal, abdo benign, FOB+O/E: Vitals normal, abdo benign, FOB+

Top 3 in DDx?Top 3 in DDx?

DefinitionsDefinitions

Diverticulosis

Asymptomatic(70%)

Diverticular bleeding(10%)

Diverticulitis(20%)

Uncomplicated(75%)

Complicated(25%)

Diverticular bleedingDiverticular bleeding 40% of all LGIB 40% of all LGIB 5% severe bleed5% severe bleed Typically Typically painless painless hematocheziahematochezia

ManagementManagement ResuscitationResuscitation Localization of bleeding siteLocalization of bleeding site

r/o UGIB, colonoscopyr/o UGIB, colonoscopy ± angiography or radionuclide scan± angiography or radionuclide scan

TreatmentTreatment SurgerySurgery

DefinitionsDefinitions

Diverticulosis

Asymptomatic(70%)

Diverticular bleeding(10%)

Diverticulitis(20%)

Uncomplicated(75%)

Complicated(25%)

DiverticulitisDiverticulitis

Diverticulum obstructed Diverticulum obstructed inflammation inflammation microperforation microperforation pericolic inflammationpericolic inflammation painpain

Diagnosis – H&P, LabsDiagnosis – H&P, Labs HistoryHistory

LLQ pain, several days, prev. painLLQ pain, several days, prev. pain

O/EO/E Fever, LLQ tenderness, Fever, LLQ tenderness, ±distension, ±mass±distension, ±mass

LabsLabs ↑↑WBCWBC

Diagnosis - ImagingDiagnosis - Imaging OptionsOptions

Plain filmsPlain films Barium enemaBarium enema Water-soluble contrast enemaWater-soluble contrast enema ColonoscopyColonoscopy CT scanCT scan

Barium enema is an appropriate Barium enema is an appropriate investigation in acute diverticulitisinvestigation in acute diverticulitis

TrueTrue FalseFalse

Spicy food can cause ulcersSpicy food can cause ulcers TrueTrue FalseFalse

Plain filmsPlain films Not useful in diagnosis of diverticulitisNot useful in diagnosis of diverticulitis Utility lies in ruling out obstruction/ Utility lies in ruling out obstruction/

perforationperforation

Barium enemaBarium enema Useful to diagnose asymptomatic Useful to diagnose asymptomatic

diverticulosisdiverticulosis CONTRAINDICATED in acute CONTRAINDICATED in acute

diverticulitisdiverticulitis Potential for barium peritonitisPotential for barium peritonitis

Water-soluble contrast Water-soluble contrast enemaenema

Less detail than bariumLess detail than barium Can see contrast collect in abscess Can see contrast collect in abscess

cavity, peritoneum, along fistulaecavity, peritoneum, along fistulae Less info than CT about disease extentLess info than CT about disease extent

ColonoscopyColonoscopy Not for acute settingNot for acute setting

CT scanCT scan Investigation of choiceInvestigation of choice SN 69-95%, SP 75-100%SN 69-95%, SP 75-100% Evaluate extent of diseaseEvaluate extent of disease Exclude other pathologyExclude other pathology If known uncomplicated diverticulitis – not If known uncomplicated diverticulitis – not

necessarynecessary

ManagementManagement UncomplicatedUncomplicated

OutpatientOutpatient AnalgesiaAnalgesia Oral AbxOral Abx

Septra/Flagyl, Cipro/Flagyl, ClavulinSeptra/Flagyl, Cipro/Flagyl, Clavulin FibreFibre F/UF/U

ManagementManagement ComplicatedComplicated

InpatientInpatient AnalgesiaAnalgesia IV AbxIV Abx Surgery vs. medical managementSurgery vs. medical management

Surgery or not?Surgery or not? First episodeFirst episode

Usually medical managementUsually medical management 3-30% recurr3-30% recurr

Subsequent episodes, Subsequent episodes, immunocompromisedimmunocompromised More likely to require surgery or More likely to require surgery or

precutaneous abscess drainageprecutaneous abscess drainage

Take home pointsTake home points Diverticulosis Diverticulosis asympt vs. IBS-like asympt vs. IBS-like

bleeding bleeding inflammationinflammation

Imaging of choice in diverticulitis is CTImaging of choice in diverticulitis is CT

Most uncomplicated pts can go homeMost uncomplicated pts can go home

Questions?Questions?

ReferencesReferences Ferri: Ferri's Clinical Advisor: Ferri: Ferri's Clinical Advisor: Instant Diagnosis Instant Diagnosis

and Treatmentand Treatment, 8th ed., 2006 Mosby, 8th ed., 2006 Mosby Leyner, Goldberg. Leyner, Goldberg. Why Do Men Have Nipples?Why Do Men Have Nipples?

2005 Three Rivers Press2005 Three Rivers Press Mandell, Bennett, & Dolin: Mandell, Bennett, & Dolin: Principles and Principles and

Practice of Infectious DiseasesPractice of Infectious Diseases, 6th ed., 2005 , 6th ed., 2005 Churchill LivingstoneChurchill Livingstone

Marx, Hockberger & Walls. Marx, Hockberger & Walls. Rosen’s Rosen’s Emergency MedicineEmergency Medicine, 6, 6thth ed., 2006 Mosby ed., 2006 Mosby

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