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Case Presentation

Case Presentation. 64 year old lady 8 week history Malaise Left sided back pain Left sciatica Right groin pain. Case Presentation. Bloods WCC 25 CRP 300 CT scan ordered. CT Scan. Gas in the portal system. CT Scan. Gas in the IMV. CT Scan. Gas in the sigmoid mesentery. CT Scan.

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Case Presentation

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  1. Case Presentation • 64 year old lady • 8 week history • Malaise • Left sided back pain • Left sciatica • Right groin pain

  2. Case Presentation • Bloods • WCC 25 • CRP 300 CT scan ordered

  3. CT Scan Gas in the portal system

  4. CT Scan Gas in the IMV

  5. CT Scan Gas in the sigmoid mesentery

  6. CT Scan Diverticulitis

  7. Background • 77 year old lady. • PMH • COPD • PAF • Previous appendicectomy, oesophagitis • Rheumatoid arthritis • DHx • Aspirin, lansoprazole, frusemide, amlodipine. • SHx • Smokes 3 cpd with 60 pack year history.

  8. Presentation • Attended A&E on 28/9/03 with fall ?cause. • Was on floor for >12 hours. • Sustained fracture to left neck of femur and admitted under orthopaedics.

  9. Post Op Course 1 • 30/09/03 • Left Thompson’s hemiarthroplasty • 1/10/03 • Patient doing well. • Post op bloods: Na 133, K 3.6, Ur 3.6, creat 53 • 2/10/03 • Hb 9.0, SaO2 87% air. IVI stopped and patient allowed to eat and drink

  10. Post op course 3 • 07/10/03 • Increased abdominal distension • Sit out, “drip and suck”, surgeons to review. • N/saline +40mmol kcl prescribed • Na 137, K 2.6, Ur 8.1, Creat 48 • Surgical review • Increased abdominal pain, no nausea • Abdomen soft, non-tender and distended • PR - empty

  11. Post op course 5 • 09/10/03. • Prescribed 8 Hourly fluids, 1L given over 16 hours – Na 148, K 2.6 • AXR Size of caecum over 14 cm, but abdomen only mildly tender. • Reviewed by on-call surgical team. • What would you do now?

  12. Neostigmine • Parasympathomimetic drug • Turegano Fuentes et al, Dis Colon Rectum, 1997 Nov;40(11):1353-7 • Resolution in 75% after single iv dose. (N=16) • Trevisani et al, Dis Colon Rectum, 2000 May;43(5):599-603 • Complete resolution occurred in 26 out of 28 patients • Time to pass flatus – 30 seconds to 10 minutes • No adverse effects or complications were noted • Ponec RJ, Saunders MD, Kimmey MB, Neostigmine for the treatment of acute colonic pseudo-obstruction. • RCT N=21, 10/11 neostigmine patients resolved, 0/10 saline responded, 7/10 in saline group responded when crossed over.

  13. Percutaneous Endoscopic Caecostomy • Salm R et al, Surg Endosc. 1988;2(2):92-95 • Successful outcome in 2 patients with failed conservative management • Ramage JI et al, Gastrointest Endosc. 2003 May:57(6):752-5 • 5 case reports. No mortality or surgical intervention in any patient. Tube remained in situ in 3 patients, removed after 10 weeks in 1 patient.

  14. Endoscopic decompression • Gellar et al. Gastrointest Endosc. 1996 Aug;44(2):144-50. • Overall clinical success was 88% (N=50) . 82% required just one treatment • Success rates improved with placement of decompression tube. • Iatrogenic perforation rate 2%

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