Clinical Pathology/Radiology Conference

Advocate Lutheran General Hospital

Diverticulitis

Sathish Babu MD

Presentation• 53 Y Caucasian male presented for elective

LAR• DOA- 12/23/07• Background- H/O IBS, depression, anxiety, N&V

since 2 years, diagnosed as having Diverticulosis, recurrent N&V- decreased GB EF- Pancreatitis- ERCP- Sphincterotomy- Cholecystectomy

• Persistent recurrent N&V, many ER visits, coffee ground emesis, no malena or BRBPR

• Endoscopies- EGD/Colonoscopy-negative except Diverticulosis of Sigmoid, CT Scan Abd/Head- negative

History• Diagnosis- Cyclic Vomiting

Syndrome- specific therapies not available

• May 2007- Diagnosed to have Mallory Weiss tear due to his vomiting about 20 times

• Oct 19th 2007- Diffuse Myalgia, Backache, fever 101.2 with Vomiting. ER- increased WCC 20, no abdominal pain, hematuria or dysuria, no rigors

• CT Scan- Oct 20th 2007-• Irrgular low-desity mass

6.2x5.1-not a simple cyst-necrotic mass, Diverticulitis

10/20/0710/20/07

10/20/0710/20/07

06/27/0506/27/05

Comparison to CT Scan done in 2005

10/23/0710/23/07

Oct 22nd 2007- CT guided Drainage- 20ml purulent fluid aspirated , 8FR pigtail catheter left in situ

•ID on board- Zosyn & Flagyl started

• Post procedure CT- abscess reduced to 3.2cms

Diverticulitis improved

History

• Abscess- GPC and GPB, Streptococci, Blood Cx- no growth

• D/C on Home ABX, liver drain came out eventually

• f/u 11/21/07- planned for Interval Colonoscopy• Colonoscopy- Dec 13th 2008-• Inflammation in Sigmoid Colon- resolving

Diverticulitis, no diverticula noted• Normal Colonoscopy otherwise• Elective Admission- 23rd 2007

H & P

• VITAL SIGNS: 114/72 mmHg, 97 F, RR 20, PR 53, 100% Sao2 • The patient in no acute distress• HEENT: EOMI, PERLA• CHEST: CTA• CVS- RRR• P/A- Soft NT/ND• Rest of the exam- normal

Initial LABS

14.0 142 106 11

11.2 261 3.7 24 1.4

42.0

132

Surgery

• 24th Dec 2008-

• Laparoscopic LAR, Hand Assisted

• Pathology- Colon Recto sigmoid resection

• -Diverticulosis and Diverticulitis, Severe

• -Peri-intestinal lymph node with reactive hyperplasia

• -Remaining colonic mucosa with no pathological change

Hospital Course• Initial Leucocytosis which settled, Uneventful

otherwise• Discharged on POD # 6 31st Dec 2007• CT Scan Abdomen- 31st Dec 2007

• F/U- doing well

12/31/0712/31/07

Literature

Med Arh. 2007 ;61 (2):117-8 17629149 [Management of liver abscess formed after asymptomatic sigmoid diverticulitis] Predrag Jovanović , Enver Zerem , Muharem Zildzić

Liver Abscess Secondary to Sigmoid Diverticulitis A Case Report- 2005

Department of Colon-Rectal Surgery

Department of Medicine, Kaohsiung Armed Forces General Hospital,

Kaohsiung, Taiwan, R.O.C

Pyogenic liver abscess secondary to asymptomatic sigmoid diverticulitis.M K Wallack, A S Brown, R Austrian, and W T Fitts

Dept of Surgery , University of Pennsylvania, Philadelphia- 1976

SummaryPyogenic Liver Abscess- RUQ pain (50%), Fever,

leucocytosis, Increased ALP and Bilirubin if biliary tract is involved

Most common cause- Biliary tract Disease-30%, Pyelephlebitis (from portal vein), Hematogenous spread, Direct extension of intra abdominal infection

Polymicrobial

PCD/PNA & IV Abx has completely replaced Surgery but Surgery is an important consideration for those who fail PCD/PNA

Intestinal Evaluation to search for cause