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Right Sided Diverticulitis - SPorter

Right Sided Diverticulitis - SPorter - Conservative...

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Conservative management versus early surgical resection in right- sided diverticulitis Steven B. Porter, MD PGY-1, Department of Surgery Team IV Rounds May 2, 2008
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2 Case presentation HPI: EM is a 53 yo F w/ PMH significant for cecal diverticulitis Dx’d in 2003 (see below) p/w 4 day hx of RLQ pain, nausea, fevers/chills, diarrhea. No vomiting. Started on cipro/flagyl PO as outpt 2 days prior to admission. Seen as outpt 1 day prior to admission. Last c-scope 2007.
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3 Case Presentation cont’d PMH: cecal diverticulitis, asthma, anxiety Meds: montelukast, sertraline, psyllium PSH: lap appendectomy/R oophorectomy 2003, lap L oophorectomy 2000 for cyst All: NKDA FHx: no diverticulitis, no colon ca SHx: no tobacco in >20 yrs, social etoh, no drugs
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4 Case Presentation cont’d PE VS: T 37.1, HR 90, BP 113/65, RR 20 Gen: NAD, speaking in full sentences CV: RRR, no murmurs Pulm: CTA b/l, no wheezes Abd: soft, +BS, TTP in RLQ, no rebound or guarding Extr: 2+ DP pulses b/l, no cyanosis, no rash Rectal: heme neg stool Labs: WBC 11.3, Hct 33.9, Plts 290, BMP WNL, INR 1.2
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5 Case Presentation cont’d The colon (arrowheads), with a small amount of contrast material in the collapsed lumen, and the diverticulum (arrow), which contains hyperattenuating material. Ii. = liver.
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6 Case Presentation cont’d Hospital Course IVF, NPO, IV antibiotics (Zosyn) Advanced to clears, pain subsided WBC decreased 11.3 7.9 5.8 Advanced to GIS D/c’d to home on Hospital Day #5 with PO antibiotics
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7 Background What are colonic diverticula? Sabiston: true diverticulum false diverticulum or pseudodiverticulum
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8 Normal Cecum Gray’s Anatomy
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9 Diverticula
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10 Pathophysiology Left-sided diverticular disease (LS): -collagen cross-linking -low fiber diet (1) Right-sided diverticular disease (RS) -?a congenital origin of true diverticulum, usually solitary(2) vs similar disease process as LS(3)
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11 Diverticulitis Occurs in 10 to 25% of people with diverticulosis. Perforation of diverticulum. LLQ pain, +/- fever, leukocytosis, and a palpable mass. Differential diagnosis includes malignancy, ischemic colitis, infectious colitis, and inflammatory bowel disease. Schwartz’s Principles of Surge
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12 Uncomplicated Diverticulitis 50 to 70% will have no further episodes. Increased risk of complications with recurrent disease. Because colon carcinoma may have an identical clinical presentation to diverticulitis all patients must be evaluated for malignancy after resolution of the acute episode. Schwartz’s Principles of Surge
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13 Complicated Diverticulitis Complicated diverticulitis includes diverticulitis with: abscess obstruction diffuse peritonitis (free perforation) or fistulas between the colon and adjacent structures.
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