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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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8 Colon
Lower GI bleeding
Presentation • Melena, hematochezia, jaundice (hemoglobin breakdown), shock, pre-renal azotemia
with high BUN (due to hypoperfusion and hemoglobin metabolism in GI)
• Must rule out upper GI bleed: Gastric lavage (60% sensitive), or endoscopy
Lavage output: Bile=UGIB ruled out; clear gastric output=indeterminate, could
be duodenal source; bloody=UGIB)
• Digital rectal examination and anoscopy to rule out anorectal bleed
Diagnosis
• Colonoscopy within 24h of index bleed
• If patient unstable➔conventional angiography with possible embolization
• If stable with rapid hemorrhage➔CT angiogram followed by conventional
angiography & embolization
231
Management
• If above workup is inconclusive and patient stable, perform
scintigraphy
• If patient stable and workup still inconclusive, consider video capsule endoscopy to
evaluate small bowel
Aggressive intravenous uid resuscitation+blood product transfusion as
needed+reverse coagulopathy
For massive transfusion (10u of blood/24h) try to maintain 1:1:1 ratio for PRBC: FFP:
Platelets
Colonoscopy: Cautery with heater probe, bipolar, laser. Mechanical clipping or banding
of diverticula; injection of epinephrine or pro-coagulant spray
Coil embolization if bleeding seen on CTA or angiography
Angiographic embolization hemostasis rate as high as 96%; 22% early rebleeding rate
If bleeding localized and not controlled with angiographic coiling➔segmental resection
(decision on anastomosis depends on stability of patient)
If unknown source and uncontrolled bleeding➔subtotal colectomy with end ileostomy
Indications for surgery: Malignancy, hemorrhage unresponsive to medical intervention,
and recurrent bleeding from a diverticulum
99m
Tc tagged RBC
Diagnostic modalities for lower gastrointestinal bleeding
Modality Characteristics and advantages Disadvantages
Angiography and
embolization
• Detects blood loss of 0.5–1ml/min
• Diagnostic and therapeutic
• Can localize the site of bleeding, if
found➔embolization
• Superselective embolization is preferred to reduce
ischemic complications
• Initial hemostatic rates approach 96%
Diagnostic yield: 30–90%
Complications: Bowel ischemia,
hematoma, contrast reaction, AKI,
and TIA
232
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Diagnostic modalities for lower gastrointestinal bleeding
Modality Characteristics and advantages Disadvantages
H. Hakmi et al.
• Detects blood loss of 0.3–0.5ml/min
• Diagnostic only
CT angiogram
Capsule endoscopy Diagnostic, as last resort once colonoscopy and
RBC scintigraphy
99m
(
Tc-tagged RBC)
Colonoscopy • Preferred study in a stable patient with self-limited
• Excellent at localizing bleeding
• CTA before angiography improves the likelihood of
angiography identifying a site of bleeding
endoscopy could not visualize source of bleeding
• Detects blood loss of 0.1ml/min
• Detects acute bleeding but does not identify other
nonbleeding causes, does not provide an etiology for
the bleeding, and is non-therapeutic
lower GI bleed
• Repeat colonoscopy might be required if non diagnostic
initially
Research about lower gastrointestinal bleeding
Reference Findings
Feuerstein JD, Ketwaroo G, Tewani SK,
Cheesman A, Trivella J, Raptopoulos V,
Lefer DA.Localizing Acute Lower
Gastrointestinal Hemorrhage: CT
Angiography Versus Tagged RBC
Scintigraphy. AJR Am J Roentgenol.
2016;207(3):578–84. https://doi.org/10.2214/
AJR.15.15714. Epub 2016 Jun 15
Both CT angiogram and RBC scintigraphy will identify active
bleeding in 38% of patients
The site of bleeding is localized with CTA in a signicantly
higher proportion of studies
Nontherapeutic
Non-therapeutic
• Most sensitive but least accurate
method for localization of GI
bleeding
• 66% accurate localizing
bleeding
Low diagnostic success in
massive lower GI bleed due to
inability to visualize
Appendicitis
Appendicitis
Risk factors Male sex and history of cystic brosis
Pathophysiology
Luminal obstruction➔bacterial overgrowth➔(vascular compromise
venous>arterial)➔necrosis➔perforation
• Obstruction in adults commonly due to a fecalith or neoplasm 1%
Most common pathogens E. coli and Bacteroides
8 Colon
Appendicitis
233
• Pain starts in periumbilical area (inamed visceral peritoneum)➔RLQ abdominal pain
(inamed parietal peritoneum), associated with anorexia, nausea, and vomiting
Sign Exam
Presentation
Diagnosis
Psoas sign Pain with passive extension or active exion of the hip
Obturator sign Right lower quadrant tenderness with exion and
external rotation of the hip
Rovsing sign Right lower quadrant tenderness upon palpation of the
left lower quadrant
Ultrasound ndings: Appendix diameter≥6mm, appendicolith, hyperemia, peri-appendiceal
uid, wall thickening
CT ndings
Appendicolith Distended appendix >6mm with wall thickening
Axial abdominal CT image with oral and IV contrast
demonstrates a dilated appendix up to 12mm with a
thickened wall and adjacent inammatory changes
Sagittal abdominal CT image with IV
contrast demonstrates a dilated appendix
with adjacent inammatory changes
(arrow) and a 1cm appendicolith
(arrowhead) at the base of the appendix
(arrow). No evidence of free air or uid collections
were noted
Periappendiceal abscess
Sagittal abdominal CT image with IV
contrast demonstrates a peripherally
enhancing uid collection with air-uid
levels and adjacent inammatory
changes (arrow) in the right lower
quadrant, consistent with periappendiceal
abscess. The appendix is not well
visualized on this examination
Axial abdominal CT image with oral and IV contrast
demonstrates a thick-walled, dilated appendix (arrow)
with an adjacent peripherally enhancing uid
collection consistent with a periappendiceal abscess
(arrowhead)
234
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Appendicitis
H. Hakmi et al.
Complicated
appendicitis
Management • Antibiotic coverage for aerobes and anaerobes
Appendicitis with perforation, phlegmon, or abscess
• Non-operative management in patients with localized peritonitis due to perforated appendicitis.
Treat with antibiotics and percutaneous abscess drainage if ≥3cm, followed by interval
appendectomy 6–12weeks after
Appendicitis in pregnancy
Presentation Pain in the right mid abdomen or RUQ if later in pregnancy
Diagnosis U/S 85% sensitive, and MRI 95% sensitive
MRI and U/S are preferable as no exposure to radiation
Management • Laparosocpic appendectomy can be performed in all trimesters
• Complicated appendicitis results in higher fetal loss rates and higher early delivery rates in
comparison to uncomplicated appendicitis
• Negative appendectomy is associated with a 4% rate of fetal loss and a 10% rate of early delivery
Appendicitis in Immunocompromised patients
Presentation More likely to present with complicated appendicitis due to late diagnosis and presentation, as the
immune response is blunted
Symptoms may be mild or discordant with radiological and surgical ndings
Management • Operative intervention should not be delayed
• If uncomplicated appendicitis without appendicolith, can opt for non-surgical management with
antibiotics in high-risk patients
Case Scenarios of appendicitis
Case Scenario Management
Uncomplicated appendicitis Single preoperative antibiotics dose+appendectomy
Nonoperative management in the absence of an appendicolith can be pursued
with a 15–25% of requiring an appendectomy within 1–2years
Complicated appendicitis
(gangrenous, abscess or
perforated) without peritonitis
Perforated appendicitis with
generalized peritonitis,
obstruction, or septic shock
Antibiotics±percutaneous drainage
Urgent operation
8 Colon
Appendectomy
Open versus laparoscopic appendectomy
Approaches Advantages and disadvantages
Open Greater hospital stay and surgical site infection risk
Laparoscopic • Shorter hospital stay
• Decreased need for postoperative analgesia
• Early food tolerance and return to work
• Lower rate of surgical site infection
Appendectomy
235
Key steps for
laparoscopic
appendectomy
Key steps for
open
appendectomy
Intraoperative
decision making
Triangulate trocar placement
Expose the appendix (landmarks: Taeniae coli converge at the base of the appendix, fold of
Treves identies the terminal ileum)
Isolate and ligate mesoappendix
Amputate the appendix without leaving a stump or narrowing the ileocecal valve
McBurney point incision (two- thirds between the umbilicus and anterior superior iliac spine)
Rocky-Davis incision is a muscle splitting transverse incision
The incision should be over the point of maximum pain or a palpable mass, if present
In the case of suspected perforated appendicitis with peritonitis beyond the right lower quadrant,
a lower-midline incision is necessary for abdominal washout
Drain placement: Only when there is a demarcated abscess cavity
Appendix difcult to visualize➔mobilize cecum medially to look for retrocecal appendix
Ruptured appendix➔skin should be approximated loosely to reduce surgical site infection
Intraoperative case scenarios and their management
Case Scenario Management
Appendicitis with cecal
involvement
Perforated cecal mass Oncologic right hemicolectomy
Appendix is normal Check terminal ileum to rule out Crohn’s disease; check for Meckel’s diverticulitis;
<2cm mass located at the
tip of the appendix
If the appendiceal base is too friable for secure transaction, a portion of the cecum
may be transected. Care should be taken to preserve the ileocecal valve and the
terminal ileum
check ovaries and tubes in females to rule out ovarian torsion, PID, ruptured ovarian
cyst
Appendectomy. Examine for peritoneal/hepatic spread. Check for mucin
extravasation. Can return for formal colectomy if necessary after pathologic
evaluation and staging
236
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Complications of appendectomy and their treatment
Complication Characteristic Management
H. Hakmi et al.
Supercial surgical
site infection
Intra-abdominal
abscess
Most common complication (1.7% in
laparoscopic; 5% in open)
Erythema
Purulent discharge
Fever, leukocytosis, ileus, abdominal pain
Around postoperative day 5–7
CT abdomen pelvis with IV and PO contrast
Research about surgical management of appendicitis
Reference Findings
Di Saverio S, etal. The NOTA Study (Non Operative
Treatment for Acute Appendicitis): prospective study
on the efcacy and safety of antibiotics (amoxicillin
and clavulanic acid) for treating patients with right
lower quadrant abdominal pain and long-term
follow-up of conservatively treated suspected
appendicitis. Ann Surg. 2014;260(1):109–17. https://
doi.org/10.1097/SLA.0000000000000560. PMID:
24646528
Salminen P, Paajanen H, Rautio T, Nordström P,
Aarnio M, Rantanen T, Tuominen R, Hurme S,
Virtanen J, Mecklin JP, Sand J, Jartti A, Rinta-Kiikka
I, Grönroos JM.Antibiotic therapy vs appendectomy
for treatment of uncomplicated acute appendicitis: The
APPAC randomized clinical trial. JAMA.
2015;313(23):2340–8. https://doi.org/10.1001/
jama.2015.6154
Patients with acute non-complicated appendicitis
without appendicolith were randomized to either
undergo appendectomy or antibiotic treatment without
appendectomy
Patients were followed for 2years
Antibiotics were safe and effective and may reduce
overall costs
Recurrence rates after 2years were less than 14% in the
antibiotic group
The 1-year rate of need for appendectomy in the
population of uncomplicated appendicitis treated with
antibiotics alone is approximately 25%. Those who
underwent appendectomy did not experience signicant
complications
Open incision and pack
Negative pressure wound management
system can be applied
Percutaneous drainage➔if not
possible➔operative drainage versus
prolonged antibiotics
Sallinen V, Akl EA, You JJ, Agarwal A, Shoucair S,
Vandvik PO, Agoritsas T, Heels-Ansdell D, Guyatt GH,
Tikkinen KA.Meta-analysis of antibiotics versus
appendicectomy for non-perforated acute appendicitis.
Br J Surg. 2016;103(6):656–67. https://doi.org/10.1002/
bjs.10147. Epub 2016 Mar 17
Fagenholz PJ, Peev MP, Thabet A, Michailidou M,
Chang Y, Mueller PR, Hahn PF, Velmahos GC.Abscess
due to perforated appendicitis: factors associated with
successful percutaneous drainage. Am J Surg.
2016;212(4):794–8. https://doi.org/10.1016/j.
amjsurg.2015.07.017. Epub 2015 Oct 20
Results showed that 8% of patients with non-perforated
appendicitis treated only with antibiotics will require
surgery within a month and a total of 29% will require
appendectomy within a year. 34% at years and 39% at
5years.
• 10% of patient who underwent an appendectomy for
recurrent symptoms at 1year had a normal appendix
on pathology
Complete resolution of abscess in perforated
appendicitis after percutaneous drainage was 78.6%
8 Colon
Research about surgical management of appendicitis
Reference Findings
237
Darwazeh G, Cunningham SC, Kowdley GC.A
systematic review of perforated appendicitis and
phlegmon: interval appendectomy or wait-and-see?
Am Surg. 2016;82(1):11–5
Loftus TJ, Raymond SL, Sarosi GA Jr., croft CA,
Smith RS, Efron PA, Moore FA, Brakenridge SC,
Mohr AM, Jordan JR.Predicting appendiceal tumors
among patients with appendicitis. J Trauma Acute
Care Surg. 2017;82(4):771–5
Nonoperative treatment of appendicitis had a
recurrence of 12%, 13% morbidity. Morbidity of
interval appendectomy of 10%. Elective interval
appendectomy implies additional operative costs to
prevent recurrence in one of eight patients
Patients with advanced age>50, absence of migratory
RLQ pain, and those with phlegmon on CT should be
considered for appendectomy at earliest convenience if
non-op management is necessary
Irritable Bowel Syndrome
Irritable bowel syndrome (IBS)
Pathophysiology Not precisely known. Likely a combination of altered motility, visceral hypersensitivity, and
altered gut microbiota. Food sensitivity also plays a role
Diagnosis Diagnosis of exclusion: Will need to rule inammatory bowel disease, infectious causes, celiac
disease, microscopic colitis, and pelvic oor disorders
Rome criteria for diagnosis: Abdominal pain associated with
Defecation Change in stool frequency Change in stool appearance
Must rule out alarming symptoms: Anemia, onset age>50, fevers, weight loss, blood in stool,
family history of inammatory bowel disease, and celiac disease
Workup: Fecal calprotectin, CBC, colonoscopy with biopsies, possible EGD.CT scan for pain,
defecography and anorectal manometry for outlet dysfunction constipation, Sitzmarker transit
study for constipation
Management Symptomatic relief with diet modication, control of medical illnesses, psychological therapy,
anti-diarrheas, anti-depressants, laxatives
Diverticulitis
Diverticulitis
Anatomy/
pathophysiology
Risk factors Low ber\high fat diet, smoking, obesity, high dose NSAIDs, opioids and constipation
Presentation Abdominal pain, nausea, vomiting, fevers, septic shock, rigidity, guarding, fecaluria,
False diverticula due to outpouching of the mucosa layer with the absence of muscularis layer
typically where vessels (vasa recta) penetrate the circular layer, between the taeniae
pneumaturia, obstipation
238
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Diverticulitis
Diagnosis
Imaging
H. Hakmi et al.
Clinical exam, CBC, and cross-sectional imaging
• CT scan of uncomplicated diverticulitis: Diverticula, colon wall thickening (>4mm),
pericolonic fat stranding
• Complicated: Free abdominal air (perforation), contained air next to colon (contained
perforation), abscess, proximal dilated bowel (large bowel obstruction), air in bladder due to
colovesticular stula
Colonoscopy should be performed before surgical resection to rule out concomitant
malignancy either at the site of inammation or elsewhere in the colon which might alter
surgical plan. (up to 11% risk of malignancy in complicated diverticulitis)
Grading
Management
Axial abdominal CT image with IV
contrast demonstrates thickened
sigmoid bowl with adjacent
inammatory changes (arrow) and a
3.3cm peripherally enhancing uid
collection (arrowhead) consistent with
complicated sigmoid diverticulitis.
Individual diverticula are difcult to
visualize due to the inammation
Hinchey classication Degree of colonic perforation
I Pericolic or mesenteric abscess
II Walled-off distant abscess (retroperitoneal or pelvic)
III Purulent peritonitis (rupture of abscess)
IV Fecal peritonitis (free bowel perforation)
Grading of types I&II is via CT scan. Differentiating types III&IV is intra-operative
Diverticulitis case Management
Uncomplicated diverticulitis Elective resection if symptoms are lifestyle limiting,
Contained perforation with
abscess
Coronal abdominal CT
image with IV and oral
contrast demonstrates an
enhancing, inamed
sigmoid diverticula with
adjacent inammatory
changes (arrow),
consistent with acute
diverticulitis
require frequent hospitalization, or if
immunocompromised
IV antibiotics, bowel rest, IVF, percutaneous drainage of
abscesses, operative intervention of non-drainable
abscesses not resolving with IV antibiotics
Axial abdominal CT image
without IV contrast
demonstrates sigmoid
diverticula with wall
thickening and adjacent
inammatory changes
(arrow), consistent with
acute diverticulitis
Free perforation with generalized
peritonitis
Failure of improvement of
uncomplicated diverticulitis
2–3days after IV antibiotics
Immunocompromised patient
with diverticulitis
Emergency operative intervention
Reimaging to evaluate for interval abscess development
More aggressive surgical management than for
immunocompetent patients
8 Colon
Diverticulitis
• Common that subsequent episodes are clinically less severe than index presentation. Urgent
Follow-up
colectomy <5% for patients with initially uncomplicated disease
• Highest risk for recurrence is in patients presenting with an abscess
• Most common reason for recurrent diverticulitis after sigmoidectomy is a Colo-sigmoid
anastomosis with retained distal diverticula. To reduce recurrence risk, anastomosis should be
to upper rectum
• After sigmoidectomy with colorectal anastomosis, 15% of patients will develop new
diverticulitis and~5% will require repeat surgery
Case scenarios for diverticulitis
Case scenario Management
Uncomplicated diverticulitis • Outpatient management with oral antibiotics (in patient without nausea/
vomiting)
239
Complicated diverticulitis without
peritonitis
Complicated
diverticulitis+peritonitis
Unstable patient in septic shock with
perforated diverticulitis
• Drain abscess percutaneously if >3cm+elective resection in 6–12weeks
Abdominal washout, sigmoid colectomy with either end colostomy
(Hartmann procedure) or primary anastomosis, with or without diverting
loop ileostomy
Abdominal washout, Hartmann procedure versus damage control laparotomy
(abdomen open and colon in discontinuity)
Research about diverticulitis
Reference Findings
Bridoux V, Regimbeau JM, Ouaissi M, Mathonnet M,
Mauvais F, Houivet E, Schwarz L, Mege D, Sielezneff I,
Sabbagh C, Tuech JJ.Hartmann’s procedure or
primary anastomosis for generalized peritonitis due to
perforated diverticulitis: a prospective multicenter
randomized trial (DIVERTI). J Am Coll Surg.
2017;225(6):798–805
Li D, Baxter NN, McLeod RS, Moineddin R, Nathens
AB.The decline of elective colectomy following
diverticulitis: a population-based analysis. Dis Colon
Rectum. 2016;59(4):332–9
Lambrichts DPV, Vennix S, Musters GD; LADIES trial
collaborators. Hartmann’s procedure versus
sigmoidectomy with primary anastomosis for
perforated diverticulitis with purulent or faecal
peritonitis (LADIES): a multicentre, parallel-group,
randomised, open-label, superiority trial. Lancet
Gastroenterol Hepatol. 2019;4(8):599–610
The rate of stoma reversal was 96% with primary
anastomosis with diverting ileostomy, signicantly
higher in comparison to 65% stoma reversal in patients
with Hartman’s procedure. Comparable morbidity and
morbidity in both groups
Percentage of patients undergoing colectomy within
1year of hospitalization for diverticulitis decreased
from 9.6 to 3.9% from 2002 to 2011
In hemodynamically stable, immunocompetent patients
with Hinchey III or IV disease, Hartmann’s procedure
was compared with sigmoidectomy with primary
anastomosis±diverting ileostomy. Results showed that
primary anastomosis is preferable to Hartmann’s
procedure
Strate LL, Liu YL, Syngal S, Aldoori WH, Giovannucci
EL.Nut, corn, and popcorn consumption and the
incidence of diverticular disease. JAMA. 2008;300(8):907–
14. https://doi.org/10.1001/jama.300.8.907
Prospective study showed no association of nuts, corn
and popcorn consumption on the development of acute
diverticulitis or diverticular bleed in men
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H. Hakmi et al.
Clostridium Dicile Colitis
Clostridium difcile Infection (CDI)
Pathophysiology CDI forms toxins A and B (toxin B is 10×> potent than toxin A) causing mucosal necrosis,
uid secretion and pseudo-membrane formation
Epidemiology • Incidence of CDI in the community is 3% in comparison to 9% nosocomial
• PPIs increase risk of CDI
• Antibiotics especially clindamycin, uroquinolones, cephalosporins and carbapenems
Prevention
Presentation • Diffuse watery diarrhea >×3, with lower abdominal pain in the absence of laxative use
Diagnosis • Stool sampling for CDI by NAAT (nucleic acid amplication) is the most sensitive. It is
Radiologic
ndings
• Spores are resistant to alcohol-based hand sanitizers➔soap and water should be used
• Contact precautions for infected patients, antibiotic stewardship
• Ileus, leukocytosis
• Can present with constipation in fulminant colitis, along with signs of septic shock
specic for toxigenic strains but does not test for active toxin production and also detects
asymptomatic carriers of toxigenic CDI
• Stool toxin B ELISA testing is less sensitive
• Don’t retest to assess cure; ~50% of patients will test positive 6weeks after treatment
CT scan with PO&IV contrast in stable patients with severe abdominal pain, distention, ileus,
hypotension, marked leukocytosis, lactic acidosis, or shock. (megacolon diagnosis if colon
diameter >6cm.)
Accordion sign and thumb printing, mucosal edema, air-uid levels. Free air suggests bowel
perforation
Axial abdominal CT image with oral
and IV contrast demonstrates diffuse
colonic wall thickening (arrows)
secondary to submucosal edema. The
“thumbprint sign” is demonstrated
(arrowheads)
Axial abdominal CT image with oral and IV
contrast demonstrates wall thickening of the
proximal colon (arrows)
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