General and Colorectal

CASE 16: leFt iliaC FoSSa pain

history

You are called to see a 66-year-old woman in the emergency department who is complaining of a 5-day history of increasing left iliac fossa pain. She vomited once yesterday and has opened her bowels normally today. She usually suffers with constipation. The pain is severe and constant with no relieving factors. She has had one previous episode a year ago, which was treated with antibiotics. She was investigated once her symptoms had subsided, but is unclear about the final diagnosis.

examination

She looks flushed, with dry mucous membranes and is febrile at 37.9°C. The pulse is 100/min with a blood pressure of 110/70 mmHg. Abdominal examination reveals localized tenderness and peritonism in the left iliac fossa. The rectum contains soft faeces on digital rectal examination. The previous investigation from a year ago is shown in Figure 16.1.

Figure 16.1 previous investigation.

Questions

•What is the above investigation and what does it show?

•What is the likely diagnosis?

•What treatment would you initiate?

•What are the possible complications?

•How can the patient prevent further episodes?

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100 Cases in Surgery

ANSWER 16

The study shown is a barium enema. There are multiple diverticula of the sigmoid colon giving a diagnosis of diverticular disease. Diverticula are outpouchings of the mucous membrane alongside the taenia coli, at the entry point of the supplying blood vessels. Diverticular disease is very common, with over 60 per cent of the population affected by the age of 80 years. It is more common in developed countries due to low-fibre diets. The low-bulk stool leads to increased segmentation of the colon during propulsion, causing increased intraluminal pressure and formation of diverticula. They are found most commonly in the sigmoid colon (95–98 per cent of diverticula), but any part of the bowel may be affected.

The majority of patients with diverticula remain symptomless. Fifteen per cent complain of colicky abdominal pain without inflammation (diverticulosis), and 5 per cent develop acute diverticulitis. The impaction of faecal material in the neck of the diverticulum leads to trapping of bacteria. The bacteria then replicate in the occluded lumen, leading to infection and inflammation. Diverticular disease is also a common cause of lower gastrointestinal bleeding. The small blood vessels, which are stretched over the dome of the diverticula, can rupture causing bleeding.

Initial investigations should include urinalysis, blood tests, blood cultures and a plain abdominal x-ray. Treatment should commence with intravenous access, intravenous fluids, analgesia, oxygen, broad-spectrum antibiotics and thromboprophylaxis. The patient should be monitored closely. Patients who do not improve after 24–48 h of treatment with antibiotics require further investigation with a CT scan of the abdomen to exclude a diverticular abscess. Patients in whom a diverticular perforation is suspected may require a laparotomy. Barium enema will confirm the diagnosis of diverticular disease, but this should not be performed in the acute setting. Once an acute episode has resolved, the patient should commence on a high-roughage diet to reduce the incidence of further attacks.

!Complications of diverticular disease

•Diverticulitis

•pericolic abscess

•Colonic stricture

•Fistulation: vagina, bladder, skin

•bacterial peritonitis: secondary to rupture of a pericolic abscess

•Faecal peritonitis: due to perforation of a diverticulum

KEY POINTS

•over 60 per cent of the population have diverticular disease by the age of 80 years.

•the majority of cases of diverticulitis will settle with conservative management.

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General and Colorectal

CASE 17: bright reD reCtal bleeDing

history

A 43-year-old man attends the surgical outpatient clinic complaining of intermittent bleeding per rectum for the past 2 months. The blood is always bright red, separate from the stool and drips into the pan. He also complains of itching around the anus. There is no other past medical history of note.

examination

Abdominal examination is unremarkable. Rectal examination and proctoscopy shows internal haemorrhoids at the 3 and 7 o’clock positions.

Questions

•What are the differential diagnoses?

•What other examinations are required?

•How would you classify haemorrhoids?

•What are the treatments for haemorrhoids?

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100 Cases in Surgery

ANSWER 17

The most likely cause for the per rectal bleeding is haemorrhoids. Haemorrhoids are congested vascular cushions containing dilated veins and small arteries. They arise from the connective tissue in the anal canal and are classically described as lying in the 3, 7 and 11 o’clock positions. A low-fibre diet results in straining with defecation, causing engorgement of the tissue. This leads to enlargement of the cushions and prolapse. Pregnancy and abnormally high tension of the internal sphincter muscle can also cause haemorrhoidal problems.

!Differential diagnoses

•anal fissure

•perianal haematoma

•Carcinoma

•anal polyp

•inflammatory bowel disease

Sigmoidoscopy is mandatory to exclude rectal pathology up to the rectosigmoid junction. If there is any doubt as to the cause of bleeding, especially in the older patient, a flexible sigmoidoscopy or full colonoscopy should be carried out.

Haemorrhoids can be classified as:

•First-degree haemorrhoids: remain in the rectum

•Second-degree haemorrhoids: prolapse through the anus on defecation but reduce spontaneously

•Third-degree haemorrhoids: prolapse but require manual reduction

•Fourth-degree haemorrhoids: prolapse and cannot be reduced

Patients should be advised to take plenty of fluid, fruit, fibre and laxatives to keep the stool soft and to avoid straining. Treatments include phenol injections into the submucosa above the haemorrhoid and/or rubber-band ligation. Large second-degree and third-degree piles may require haemorrhoidectomy.

KEY POINT

• eighty per cent of patients will not require surgical intervention.

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