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It s More than Cellulitis

Learning Objective. Discuss differential diagnosis of truncal cellulitis . History of Present Illness. 64 year old femaleHPIBack pain, skin tightness, chills, feverDuration: 3 weeksROSConstipation x 2 weeksChronic reflux symptoms. PMH / Social / Fam Hx. PMH: Hysterectomy 1980Medications: A

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It s More than Cellulitis

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    1. It’s More than Cellulitis! Stephanie L. Baer MD Lisa L. Willett MD Division of General Internal Medicine

    2. Learning Objective Discuss differential diagnosis of truncal cellulitis

    3. History of Present Illness 64 year old female HPI Back pain, skin tightness, chills, fever Duration: 3 weeks ROS Constipation x 2 weeks Chronic reflux symptoms

    4. PMH / Social / Fam Hx PMH: Hysterectomy 1980 Medications: Aspirin product prn 2-3/d SH Smoker: 40 pack years Alcohol: 3-4 beers / day FH Mother: stroke, HTN Father: colon cancer, MI

    5. Physical Exam BP 126/54 HR 96 RR 14 T 99.9şF Obese, non toxic Cardiac Systolic murmur 3/6 Abdomen BS normal Not tender or distended, no masses

    6. Physical Examination Extensive erythematous, indurated, warm, trunk Left flank from sacrum to left lower quadrant, extending almost to the axilla

    7. Evaluation WBC 22.2 /ľL (11% bands) HCT 27.5 % PLT 670 /ľL LFT TP 5.6 g/dL Alb 2.0 g/dL AST 67 U/L ALT 66 U/L Transthoracic echo: no vegetations, IHSS

    8. Hospital Course

    9. CT Scan

    10. Follow Up

    11. Barium Enema

    12. Follow -Up Surgery: resection, diverting colostomy Discharged with wound vacuum device Uneventful follow up for 10 months

    13. Colocutaneous Fistula Rare complication of diverticulitis Prevalence 1-4% of patients with diverticulitis Asymptomatic: 50%, except for external drainage of feces Suspect in abdominal or truncal cellulitis Bahadursingh Am J of Surgery 2003;186:696-71. Stollman, Amer J Gastroenterol 1999;94:3110-21 Vasilevsky, Int J Colorectal Dis 1998;13:57-60. Mahler, J Amer Coll Surg 2003;197:517 Bahadursingh Am J of Surgery 2003;186:696-71. Stollman, Amer J Gastroenterol 1999;94:3110-21 Vasilevsky, Int J Colorectal Dis 1998;13:57-60. Mahler, J Amer Coll Surg 2003;197:517

    14. Risk Factors Inflammatory bowel disease Colon cancer Diverticulitis Diverticular abscess Prior abdominal surgery

    15. Causes of Abdominal Wall Abscess Iatrogenic (post operative complication) Infections Amebiasis, non-typhi salmonellosis Pyelonephritis Gallbladder disease Adenocarcinoma of the transverse colon Colonic diverticulitis with perforation Jejunal diverticuli Trauma Inflammatory bowel disease Eriguchi, J Gastroenterol 1998;32:272-5 Eriguchi, J Gastroenterol 1998;32:272-5

    16. Diagnostic Tests Computed tomography Barium enema Aspirate abscess Surgical exploration Bahadursingh Am J Surg 2003;186:743-6 Riaz, Eur J Surg 2001;167:924-6 Bahadursingh Am J Surg 2003;186:743-6 Riaz, Eur J Surg 2001;167:924-6

    17. Treatment Antibiotics Surgical resection

    18. Conclusions High index of suspicion in truncal cellulitis Especially past history of abdominal surgeries Colocutaneous fistula is a rare complication of a common disease Diagnosis: CT or barium enema Treatment: surgery, antibiotics

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